Laryngeal dysplasia: a long-term follow-up study.

PURPOSE: To assess the progression of precancerous laryngeal lesions to squamous cell carcinoma (SCC), defined by specific histopathological criteria, in patients with longterm follow-up. METHODS: Patients with laryngeal dysplasia, followed/ treated between 1985 and 2008, were retrospectively evaluated and classified according to the World Health Organization classification system (WHO). The investigated outcome parameters were progression of dysplasia to SCC, time interval to malignant transformation and continuation of smoking as potential risk factors. RESULTS: Fifty-nine patients were studied. Progression of dysplasia to SCC between the first and the final histological examination was statistically significant (p<0.0001). Malignant transformation appeared in 29 patients (49.2%). Serious dysplasia was more likely to progress to SCC (64.8%) compared to mild (41.7%) or moderate (44.4%) (p<0.0001). However, the time interval needed in these 29 cases to progress to cancer was not statistically related to the initial histological diagnosis. Continuation of smoking did not affect the progression of disease. However, the mean time from dysplasia to laryngeal cancer was much longer in patients who quitted smoking (33.5 months) vs those who continued smoking (19.5 months), with a marginal statistical difference (p=0.057). CONCLUSION: All patients with laryngeal dysplasia should be followed up at regular intervals. The progression of dysplasia to SCC did not seem to be directly related to the continuation of smoking or not. However, large long-term follow- up studies taking into account the degree of exposure (e.g. time of exposure, number of cigarettes) are needed in order to clarify risk factors and proper management. Consensus guidelines in diagnosis, follow-up, and treatment would improve substantially the current clinical practice.

The effect of functional endoscopic sinus surgery on patients with asthma and CRS with nasal polyps.

AIM: To study the effect of functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis (CRS) and nasal polyps (NP) with concomitant asthma. DESIGN: The study was designed to evaluate prospectively whether FESS can influence parameters of asthma in patients with CRS with nasal polyps. METHODS AND RESULTS: One hundred thirty seven patients were recruited from the ENT-Allergy and Panedoscopy Clinic of the ENT Department. All selected patients underwent medical therapy for CRS and NP for 12 weeks, and in case of no improvement, they proceeded to surgical treatment. They also underwent pre- and post-treatment subjective and objective measurements for CRS and asthma. In the study, 86 patients were finally evaluated who completed the protocol and were followed up for a period of 12 months. The patients showed statistically significant improvement of the objective measurements for asthma, from baseline to six and twelve months follow-up. No significant increase was found in the proportion of patients with well or very well overall asthma-control during the follow-up period. There was a clear improvement in the use of bronchodilators, oral steroids and need for hospitalization for asthma. CONCLUSIONS: Obviously, there is a link between CRS with NP and asthma. The data analysis of our study supports the hypothesis that FESS could have beneficial effect on both diseases improving objective and subjective measurements.

Long-term results of plastipore prostheses in reconstruction of the middle ear ossicular chain.

PURPOSE: To examine the acoustic results over a long period of time, in patients who underwent ossiculoplasty with Plastipore, and to report the percentage of prosthesis extrusion and factors related to the prognosis. PROCEDURES: Forty-two patients, who underwent ossiculoplasty with Plastipore, were studied. Patients were followed up for the next 14 years. The surgical procedures were classified as: tympanoplasty, tympanoplasty with mastoidectomy with canal wall up, and tympanoplasty with mastoidectomy with canal wall down. A successful hearing result was defined as a postoperative air-bone gap (ABG) of 20 dB or less. RESULTS: Successful results were seen in 65% of our patients, 68.8% with a partial ossicular replacement prosthesis (PORP) and a 62.5% success rate with a total ossicular replacement prosthesis (TORP). The mean value for ABG improvement was 25.5 dB. Prosthesis extrusion occurred in 4.7%. CONCLUSIONS: The ossiculoplasty-Plastipore technique leads to good hearing results and a low percentage of prosthesis extrusion in long-term follow-ups.

Immunohistochemical detection of E-cadherin in certain types of salivary gland tumours.

OBJECTIVES: To investigate the topography of E-cadherin and its possible correlation with the histological phenotype of salivary gland tumours. MATERIAL AND METHODS: Archival formalin-fixed, paraffin-embedded sections of 54 benign and 56 malignant tumours and 24 samples of normal and inflamed salivary gland tissue were studied immunohistochemically using an Envision/horseraddish peroxidase (HRP) technique. RESULTS: In normal and inflamed salivary gland samples, E-cadherin was expressed at the membrane of acinar, myoepithelial and ductal cells located at cell-cell contact points. Reduction and/or absence of E-cadherin was only observed in pleomorphic adenoma at the peripheral cells of the duct-like or island structures, or in the cells exhibiting plasmacytoid or stromal differentiation. Neoplastic epithelium in Warthin's tumours and in myoepithelial and oncocytic adenomas was strongly positive. Furthermore, a weak to moderate loss of expression which was related to tissue tumour subtype was seen in malignant tumours such as: adenoid cystic carcinomas; polymorphous low-grade adenocarcinomas; acinic cell carcinomas; and mucoepidermoid low-grade, epithelial-myoepithelial, lymphoepithelial and squamous low-grade carcinomas. Moderate to extreme loss or alternative cytoplasmic non-functional expression were observed in cases of salivary ductal carcinoma, carcinosarcoma, myoepithelial carcinoma, oncocytic adenocarcinoma, unspecified adenocarcinoma and squamous high-grade carcinomas. CONCLUSION: This study suggests a direct association of E-cadherin expression with neoplastic histologic phenotype, which is lost in the more undifferentiated and invasive epithelial salivary gland tumours.

p53, p21 and p27 protein expression in head and neck cancer and their prognostic value.

Histological specimens from 62 laryngeal and 31 oral carcinomas were immunohistochemically assessed for p53, p21 and p27 proteins; cases with > 10% labelled nuclei were considered as positive. p21 showed higher expression in patients > 65-years-old (P = 0.04), in chemotherapy responders (P = 0.02), and in stage III patients with longer overall survival (P = 0.02), representing the only independent prognostic factor in the multivariate analysis. In addition, stage III patients with p53-/p21+ showed the longest survival whereas those with p53+/p21- tumors showed the shortest overall survival (P = 0.02). A significant influence on the survival of stage III patients was also found for the combinations of p21 and p27 proteins with p21+/p27- imparting the best and p21-/p27+ the worst prognosis (P = 0.04). p27 expression was significantly related to oral cancer specimens (P = 0.04) and to moderate and high tumor grade (P = 0.01). p53 expression was not significantly related to any of the examined clinicopathological characteristics. Our findings indicated that, by functionally promoting apoptosis, p21 seems to play a key role in the successful response to chemotherapy and may be considered as a predictive factor of a better prognosis in stage III patients with head and neck cancers.

Modified supracricoid partial laryngectomy with cricohyoidopexy: series report and analysis of results.

Aiming to improve voice quality and to facilitate swallowing rehabilitation, we modified the supracricoid partial laryngectomy with cricohyoidopexy by preserving the posterior segment of the true vocal cord on the less involved side of the larynx. Between 1983 and 1994, 13 patients with supraglottic cancer were treated with this modified procedure. The possibility of incomplete tumor excision was eliminated by careful patient selection and intraoperative reconfirmation of tumor extent with frozen sections. Our results have been promising, with a 76.9% 3-year survival rate and a 69.2% laryngeal preservation rate. There were 7 recurrences, 3 local (2 at the superior border of the cricoid and 1 at the cricoarytenoid region) and 4 nodal, in 5 patients. Distant metastases developed in another patient. Three patients, 2 with local and nodal recurrence and 1 with distant metastases, died of disease. Functional outcomes were also good, with all patients achieving normal swallowing by the end of the first year, although 5 patients required temporary gastrostomy for transient swallowing impairment. Early decannulation and satisfactory voice quality were achieved in all cases. We believe that with proper patient selection this modified procedure is effective both for tumor control and for preserving a more functional larynx.

Management of bilateral vocal fold paralysis: experience at the University of Athens.

The treatment of patients with vocal fold paralysis presents a challenge to the otolaryngologist-head and neck surgeon. Many techniques have been proposed to manage individuals with unilateral or bilateral vocal fold paralysis. We herein describe the experience of our department in dealing with bilateral vocal fold paralysis. At the University of Athens, patients presenting with symptomatic bilateral paralysis are treated with a posterior cordectomy by using the CO2 or KTP-532 laser. During the last 5 years, we have treated 20 patients (8 men and 12 women) presenting with symptomatic bilateral vocal fold paralysis. For augmentation of the glottic airway, a modification of Kashima's cordotomy was used, completing a partial posterior cordectomy of one or both true and false vocal folds with the CO2 laser (15 patients) and the KTP-532 laser (5 patients). An elective tracheotomy was done before the cordotomy. Complications, such as infection, stridor, or dyspnea, were minimal. Although no objective voice analysis was performed, all patients were able to communicate without any phonation device and were satisfied with the result of the surgery. When compared with other techniques, the advantages offered by the posterior cordectomy included rapidity and simplicity in concept, reliability of outcome, short hospitalization, low risk of complications, and the possibility for revision when necessary (posterior cordectomy). From the successful postsurgical results of this study, it can be concluded that the posterior cordectomy is a reliable treatment option for the management of patients with bilateral vocal fold paralysis.

The point prevalence of otitis media with effusion among school children in Greece.

Tympanometry, pneumatic otoscopy and acoustic reflex tests performed on 5121 school children aged 6-12 years old, during late spring and early autumn of 1996. Demographic, social, medical and birth related data were collected for each child separately. The study was undertaken in order to evaluate the prevalence of otitis media with effusion in a sample of the general population in Greece and to investigate the correlations with possible risk factors. A total of 6.5% had unilateral or bilateral type B or C2 tympanogramms, and negative reflex suggestive of otitis media with effusion. The finding indicates a rather low prevalence of otitis media with effusion in school children in Greece compared with other countries. This study, also has shown that there was a statistical significant relationship between secretory otitis media (SOM) and, age, sex, mother's education, parental smoking, breast-feeding, allergy and previous otitis media. No correlation was found in relation to the climate of residence, premature birth, number of siblings, mother's gestational age, birth skull circumference, birth body weight and length.

Intramasseteric metastasis of renal cell carcinoma.

In this case report, we present a solitary metastasis of renal cell carcinoma inside the masseter muscle. To our knowledge, it is the very first case ever encountered.

Otolaryngological treatments in hagiographical Byzantine texts (324-1453 A.D.): miracles or reality?

Hagiographical texts of the Byzantine period contain a significant number of miraculous treatments of several diseases of the ear, nose and throat. The comparison of the conservative treatments referred to as well as the often concealed surgical interventions of these texts with those known from the medical texts of the eminent Byzantine physicians, lead the writers to conclude that a series of real treatments were carried out in the churches or in the Xenones (hospitals) of Byzantium.

Actinomycosis of the thyroid gland masquerading as a neoplasm.

Actinomycetal infections involving the head and neck often pose a diagnostic puzzle to the otolaryngologist. A rare case of unilateral thyroid swelling due to actinomycosis is described. Although the clinical, laboratory and imaging studies strongly suggested a thyroid neoplasm, the histological examination revealed the presence of Actinomyces sp. in the excised lesion. The manifestations of actinomycosis of the head and neck, its pathogenesis and the difficulties encountered in the diagnosis and treatment of the disease are hereby reviewed.

Localized mastoiditis simulating a facial nerve schwannoma on MRI.

A case of a single inflamed mastoid air cell is described. This was initially interpreted as a facial nerve schwannoma on MRI examination. Careful evaluation of the signal characteristics and additional findings from the high resolution CT examination helped to establish the correct diagnosis.

CO2 and KTP-532 laser cordectomy for bilateral vocal fold paralysis.

Laryngeal obstruction due to bilateral vocal fold paralysis has been treated in many different ways. The CO2 laser or KTP-532 laser endoscopic cordectomy described in this report is a slight modification of the posterior partial cordectomy proposed by Dennis and Kashima. This technique was used in 18 patients (14 with the CO2 and four with the KTP-532 laser). Prophylactic tracheostomy was performed pre-operatively. Post-operative results were excellent in nine cases, good in seven cases and poor in two cases who had to remain with a permanent tracheostomy tube with a speaking valve. The main complications noted were the formation of a granuloma (seven cases) and arytenoid oedema (six cases). Revision surgery was performed in the seven cases with granuloma formation and in the two with persistent oedema. The results and the post-operative findings from the use of the two lasers were similar.

Stapedotomy in osteogenesis imperfecta patients.

Osteogenesis imperfecta (OI) is a connective tissue disorder characterized by osseous fragility, blue sclerae and hearing loss. In order to assess the impact of stapedotomy on improving hearing on OI, a retrospective, one-group, pre-test-post-test design was used to compare the pre-operative and post-operative audiograms of nine OI patients, treated with stapedotomy for their mixed hearing loss. Operative findings included fixation or thickening of the stapes footplate with normal superstructure configuration and hypervascularization of the promontory mucosa. Immediate post-operative results showed a significant improvement (p < 0.05) from 250-4000 Hz in air conduction and from 250-2000 Hz in bone conduction. A significant closure of the air-bone gap between 250-2000 Hz was also achieved (p < 0.05). The long-term results remained satisfactory with a mean threshold shift of 8 dB HL and an almost unchanged air-bone gap. These satisfactory results and the lack of complications make stapedotomy an appealing method for the management of OI-associated hearing loss.

Laryngeal tuberculosis at the end of the 20th century.

Despite the dramatic reduction in the incidence of laryngeal tuberculosis after the 1950s, the topic has now gained new interest due to claims that the disease has changed its clinical pattern. In the past, the typical patient was 20-40 years old with ulcerated laryngeal lesions, perichondritis, and advanced cavitary lung disease. We studied nine cases of laryngeal tuberculosis confirmed by histological examination. The microlaryngoscopy revealed tumour-like lesions and/or chronic non-specific laryngitis. There were no significant ulcerations or signs of perichondritis. The patients' ages ranged from 48.5 years to 69.3 years (mean, 59.4 years). In three of our patients (33 per cent) we did not find any pulmonary involvement, thus suggesting primary laryngeal tuberculosis or haematogenous spread. In conclusion, the numerous physicians who deal with the various laryngeal symptoms and diseases should be aware of the existence of laryngeal tuberculosis and the changing patterns of the disease (at least in the developed countries).

Aggressive verrucous carcinoma of the paranasal sinuses invading the orbit: case report and literature review.

INTRODUCTION: Verrucous carcinoma is a variant of well differentiated squamous cell carcinoma characterised by an exophytic, warty growth which is slowly but locally invasive and which can cause extensive local destruction if left untreated. CASE REPORT: We report the first known case of veruccous carcinoma of the paranasal sinuses with rapid orbital invasion. A 58-year-old man presented with right-sided nasal obstruction, a huge right intranasal lesion, intractable dacryocystitis and cutaneous involvement of the nasolacrimal sac region. The tumour was partially removed using an endoscopic transnasal approach. Post-operatively, and while waiting for the histological result, the patient developed signs of rapid invasion of the orbit, with uniocular visual acuity deficit. He underwent combined radiochemotherapy, with a moderate response. CONCLUSION: Knowledge of the potentially aggressive nature of verrucous carcinoma may be helpful in early management of intraorbital invasion and salvaging of the eye.

Laryngeal pemphigus without skin manifestations and review of the literature.

Pemphigus is an uncommon chronic disease with dermatologic and mucosal manifestations. Primary laryngeal involvement without skin lesions is extremely rare. The present paper describes a 72-year old man who presented with a 2-month history of hoarseness, haemoptisis and dysphagia. Clinical examination revealed an erythematous oral mucosa without ulcerations. Indirect laryngoscopy revealed supraglottic ulcerations mainly in the laryngeal surface of the epiglottis and in the right arytenoid. The lesions had characteristic gray color membranes. The patient underwent microlaryngoscopy under general anesthesia and biopsies were taken for histology that revealed inflammatory and granular lesions with necrosis. The diagnosis of pemphigus was based on immunohistopathology and the clinical examination. The patient underwent intravenous treatment with high doses of corticosteroids (prezolon 75 mg/24 h) for 10 days and gradually the dose was reduced to 10 mg/24 h. The patient had a very good response to the treatment and after a week approximately 80% of the lesions disappeared. However, the dose of 10 mg prednisolone per day was sustained for 3 months because any attempt of prednisolone discontinuation was related with reappearance of the clinical symptoms. After 3 months, finally the treatment was discontinued without problems. Now, 15 months later, the patient is well and without symptoms. He is under long-term follow-up. ENT surgeons should be aware of pemphigus as primary laryngeal manifestation in order to investigate and manage patients accordingly.

Should we use ossicular remnants in ossicular reconstruction following cholesteatoma removal?

The remnants of the acoustic ossicles have been used in ossicular reconstruction during mastoid surgery for many decades. The present study assessed the status of the acoustic ossicles in 114 patients (57 with cholesteatoma and 57 without) during surgery for chronic otitis media using the operating microscope. In 52 cases, the ossicles (malleus and/or incus) were assessed using both the surgical and scanning electron microscope in order to reveal any erosions and compare the findings. From the 57 operated ears with cholesteatoma, 45 (79%) had ossicular erosion whereas 12 (21%) did not. In the group of 57 operated ears with chronic otitis media without cholesteatoma, 33 (58%) had ossicular erosion whereas 24 (42%) did not. This difference was statistically significant (p = 0.02). With regard to the 52 operated cases who were studied with both microscopes, in the cholesteatoma patients the surgical microscope was not able to reveal any ossicular erosions in 39% of the cases, whereas the scanning electron microscope revealed moderate or severe erosions in the same ears. This suggests that the operating microscope is not reliable enough to determine if ossicular remnants can be used in ossicular reconstruction following cholesteatoma surgery. There is a considerable risk that epithelia or other cholesteatoma particles remain in the areas of erosions that cannot be seen with the operating microscope. The use of such ossicular remnants may lead to cholesteatoma recurrence and failures in mastoid surgery. Therefore, autoclaving or alternative prosthesis may be considered in such cases.

Burkitt's lymphoma in the base of the tongue: differential diagnosis and management.

Burkitt's lymphoma is the most common malignancy in African children but can occur sporadically in every country. It is one of the most aggressive malignancies in the human body, and in the past the prognosis was very poor. However, complex chemotherapy regimens can now cure approximately 50-80% of adult patients with Burkitt's lymphoma or small noncleaved lymphoma, and in pediatric populations the cure rate is even higher. Although the African type has a preference to the head and neck region (whereas the sporadic type to the abdomen), involvement of the base of the tongue is extremely rare as only 1 case has ever been reported in the English literature. The present study describes a patient with Burkitt's lymphoma presenting as a single mass in the base of the tongue without any abdominal or other extra-abdominal involvement. The patient was submitted to chemotherapy (intravenous and intrathecal) and skull radiotherapy. Today, 17 months after the diagnosis, the patient is disease free. Physicians should be aware of the extranodal manifestations of Burkitt's lymphoma and their differential diagnosis in order to achieve early diagnosis and treatment.