Nasal Extranodal Natural Killer/T-cell Lymphoma Imitating Squamous Cell Carcinoma: A Case Report.

Nasal extranodal NK/T-cell lymphoma (NNKTL) is a lethal disease due to poor prognosis with rapid progress. A 56-year-old man complained of left nasal obstruction and blood-stained nasal drip for two months. Incisional biopsies were performed at the outpatient department three times, and the diagnosis of SCC was made. The patient underwent wide excision of the entire lesion via endoscopic sinus surgery with navigation. Final pathologic report revealed NNKTL. Pathological examination of the tumor revealed overlying epithelium presenting as pseudoepitheliomatous hyperplasia (PEH), which mimicked SCC invasion, with infiltration of atypical lymphocytes in the deeper sections. Immunohistochemistry supported the diagnosis of NNKTL. Chemoradiotherapy was administered, and a complete response was achieved at the two-year follow-up. The correct diagnosis of NNKTL is essential for prompt treatment and prevention of superfluous surgery. Although the link between PEH and NNKTL may lead to a misdiagnosis of SCC, multiple large and deep biopsies can prevent this dilemma. A biopsy showing ulceration or necrosis can indicate PEH and imply potential malignancy. Repeated biopsies and complete immunohistochemical studies are important for diagnosing NNKTL.

Increased nasality of connected speech in patients underwent modified Lothrop procedure for refractory chronic rhinosinusitis: Cross-sectional and prospective study.

BACKGROUND: The endoscopic modified Lothrop procedure (EMLP) is performed to create a large frontal neostium in patients who had failed previous frontal sinus surgeries. EMLP causes obvious changes in the volume and anatomy of the sinuses, which may cause a more significant change in nasality. This study aimed to evaluate the changes in nasalance in patients who underwent EMLP by comparing their preoperative nasalance to the established normative values and postoperative nasalance. METHODS: This was a prospective study. Twenty-one patients diagnosed with refractory frontal sinusitis who were indicated to undergo EMLP were enrolled. One hundred one healthy participants were enrolled as norm references. The Nasometer II Model 6400 (KayPENTAX) was used to analyze the nasalance scores. Nasalance scores were tested before surgery and 1 and 3 months after the surgery. RESULTS: The normative references of nasalance were (mean ± SD) 14.6% ± 6.7%, 39.4% ± 8.4%, and 55.8% ± 8.3% for the oral passage, oral-nasal passage, and nasal sentences, respectively. The mean nasalance scores pre-EMLP and 1 and 3 months post-EMLP were 23.2% ± 9.6%, 29.0% ± 9.3%, and 29.9% ± 0.4% for the oral passage; 48.7% ± 10.7%, 54.7% ± 7.7%, and 56.4% ± 7.2% for the oral-nasal passage; and 62.7% ± 10.9%, 69.8% ± 6.7%, and 70.7% ± 6.4% for the nasal sentences, respectively. Compared with the normative references, pre-EMLP nasalance was higher for all the three speech stimuli (t-test, p < 0.05). Post-EMLP nasalance also significantly increased for all the three stimuli at the 1- and 3-month follow-up visits (Paired t-test, p < 0.05). CONCLUSION: EMLP has a short-term impact on resonance; however, long-term follow-up is required for further study.

Factors influencing surgeon decision-making by measuring waiting time for pediatric ventilation tube insertions.

BACKGROUND: The surgeon and physician's decision-making may be influenced by many factors. The clinical practice guideline suggested that watchful waiting for 3 months should be the initial management for pediatric otitis media with effusion. The waiting time of ventilation tube insertion for pediatric patients is a proper measurement for physician decision-making. This study investigated factors influencing the waiting time for pediatric ventilation tube insertion and to explore factors influencing physician decision-making. METHODS: Information associated with all patients under 18 years of age who received ventilation tube insertions from July 1, 2000 to December 31, 2009 were retrieved and analyzed from a nationwide, population-based administrative database. The waiting time before ventilation tube insertions from the time of diagnosis of otitis media with effusion was recorded. Certain factors that would influence the waiting time were identified. At the same time, how these factors influenced clinical decision-making were also identified. RESULTS: The waiting time decreased as patient age increased (p < 0.001), and increased as the recent frequency of upper respiratory tract infection diagnosis increased (p < 0.001). Patients who received simultaneously bilateral ventilation tube insertions had shorter waiting time than those who had unilateral surgery (p < 0.01) and patients who had undergone ventilation tube insertions in a tertiary referral center generally had longer waiting times (p < 0.001). CONCLUSION: The waiting time of ventilation tube insertions for pediatric otitis media with effusion can be influenced by many factors. Patients with older age and undergone simultaneously bilateral ventilation tube insertion had shorter waiting time. Patients who had more upper respiratory tract infection episodes and who received ventilation tube insertions in a tertiary referral center setting were subject to longer waiting times.

A Giant Schwannoma Extending from Medial Portion of Middle Cranial Fossa to Parapharyngeal Space and Deep Parotid Space.

Trigeminal schwannomas are rare tumours comprising 0.2% of all intracranial tumours and 0.5% of all head and neck tumours. Patients with trigeminal schwannomas presented with facial hypoesthesia and pain. We presented a case with left bulging oropharynx. The CT scan showed a 3.8x2.6x4.9cm left parapharyngeal tumour compressed to the oropharynx and middle cranial fossa. We performed 3 ways in two times of operation to excise the whole tumour. We chose the transoral approach for parapharyngeal space, trans-parotid approach for deep parotid part and the endoscopic endonasal trans-pterygoid approach and trans-maxillary with Canine fossa trephination for intracranial lesions. The pathology showed schwannoma. A huge schwannoma extended from intracranial to several spaces is difficult to resect just by one approach. We should separate the tumour to several parts by clinical image before the operation and design a plan to remove the whole tumour in different approach. The different space of tumour involvement had several ways to access. We needed to choose the less harm but with better surgical field.

Olfactory Outcomes After Middle Turbinate Resection in Endoscopic Transsphenoidal Surgery: A Prospective Randomized Study.

OBJECTIVE: Endoscopic endonasal transsphenoidal surgery is safe and effective for sellar and parasellar tumor removal. Partial middle turbinate (MT) resection is sometimes performed to optimize the surgical field and facilitate postoperative care. Disturbances in olfaction are concerning because of the lack of randomized studies in this field. STUDY DESIGN: Prospective randomized trial. SETTING: Single academic medical center. METHODS: We resected the lower halves of bilateral MTs in the resected group and laterally fractured bilateral MTs in the preserved group. Olfactory outcomes and sinonasal conditions were assessed by using the validated Taiwan Smell Identification Test and Lund-Kennedy Endoscopy Score, respectively. Forty-nine patients were enrolled in the final analysis, of whom 23 underwent partial MT resection. RESULTS: The average Taiwan Smell Identification Test result was 36.9 one month after surgery, with a significant change of -4.4 ± 3.1 (mean ± SD; P < .01) from baseline. The impact was not significant at 3 months (-2.1 ± 2.6, P = .13) or 6 months (0.3 ± 2.0, P = .79). Between the MT resection and preservation groups, there were no significant differences at postoperative 1 month (P = .60), 3 months (P = .86), and 6 months (P > .99). Lund-Kennedy Endoscopy Score was still higher at 3 months (P = .006) after surgery but returned to the preoperative level at 6 months (P = .63). CONCLUSIONS: Endoscopic endonasal transsphenoidal surgery may affect olfaction at 1 month after surgery, and olfactory function is expected to return after 3 months. Partial MT resection did not result in additional olfactory loss. It is safe to perform partial MT resection during surgery without compromising the olfactory outcomes.

Dysregulation of Dual-Specificity Phosphatases by Epstein-Barr Virus LMP1 and Its Impact on Lymphoblastoid Cell Line Survival.

The strongest evidence of the oncogenicity of Epstein-Barr virus (EBV) in vitro is its ability to immortalize human primary B lymphocytes into lymphoblastoid cell lines (LCLs). Yet the underlying mechanisms explaining how the virus tempers the growth program of the host cells have not been fully elucidated. The mitogen-activated protein kinases (MAPKs) are implicated in many cellular processes and are constitutively activated in LCLs. We questioned the expression and regulation of the dual-specificity phosphatases (DUSPs), the main negative regulator of MAPKs, during EBV infection and immortalization. Thirteen DUSPs, including 10 typical and 3 atypical types of DUSPs, were tested. Most of them were downregulated after EBV infection. Here, a role of viral oncogene latent membrane protein 1 (LMP1) in limiting DUSP6 and DUSP8 expression was identified. Using MAPK inhibitors, we found that LMP1 activates extracellular signal-regulated kinase (ERK) or p38 to repress the expression of DUSP6 and DUSP8, with corresponding substrate specificity. Morphologically, overexpression of DUSP6 and DUSP8 attenuates the ability of EBV-immortalized LCL cells to clump together. Mechanistically, apoptosis induced by restoring DUSP6 and DUSP8 in LCLs indicated a novel mechanism for LMP1 to provide a survival signal during EBV immortalization. Collectively, this report provides the first description of the interplay between EBV genes and DUSPs and contributes considerably to the interpretation of MAPK regulation in EBV immortalization.IMPORTANCE Infections by the ubiquitous Epstein-Barr virus (EBV) are associated with a wide spectrum of lymphomas and carcinomas. It has been well documented that activation levels of MAPKs are found in cancer cells to translate various external or intrinsic stimuli into cellular responses. Physiologically, the dual-specificity phosphates (DUSPs) exhibit great ability in regulating MAPK activities with respect to their capability of dephosphorylating MAPKs. In this study, we found that DUSPs were generally downregulated after EBV infection. EBV oncogenic latent membrane protein 1 (LMP1) suppressed DUSP6 and DUSP8 expression via MAPK pathway. In this way, LMP1-mediated MAPK activation was a continuous process. Furthermore, DUSP downregulation was found to contribute greatly to prevent apoptosis of EBV-infected cells. To sum up, this report sheds light on a novel molecular mechanism explaining how EBV maintains the unlimited proliferation status of the immortalized cells and provides a new link to understand EBV-induced B cell survival.

Free mucosal grafts and anterior pedicled flaps to prevent ostium restenosis after endoscopic modified Lothrop (frontal drillout) procedure: a randomized, controlled study.

BACKGROUND: The endoscopic modified Lothrop procedure (EMLP) is used to manage ongoing refractory frontal sinusitis after failed previous endoscopic sinus surgery (ESS), but this approach has a significant restenosis rate. We evaluated the potential benefits of mucosal grafts and pedicled flaps on the opening of the newly formed frontal ostium. METHODS: Fifty patients with refractory frontal sinusitis or mucoceles after ESS were randomized to undergo EMLP, either with (n = 27) or without (n = 23) mucosal grafts and pedicled flap reconstruction of the neo-ostium. The frontal neo-ostium was measured with Lindholm distending forceps, and anteroposterior (A-P) and lateral dimensions were measured intraoperatively, and then again at 6 weeks, 6 months, and 12 months postoperatively. Olfaction outcomes were assessed using the Taiwan Smell Identification Test (TWSIT) and a smell visual analog scale (VAS) score preoperatively and at 6 months postsurgery. RESULTS: The initial intraoperative mean lateral and A-P dimensions were 23.2 ± 2.7 mm and 14.8 ± 2.3 mm and were significantly decreased at all time-points postoperatively. The mucosal grafts and pedicled flaps had greater lateral and A-P dimensions, and a greater percentage of intraoperative frontal neo-ostium area at all time-points postoperatively (all p < 0.05). At 6 months postoperatively, TWSIT (p = 0.027), but not the smell VAS score (p = 0.063), was significantly improved compared with baseline. TWSIT and smell VAS score changes did not differ between groups (p = 0.92 and p = 0.85, respectively). CONCLUSION: The use of mucosal grafts and pedicled flaps reduces stenosis of the frontal neo-ostium postsurgery and should be considered after EMLP.

Epidemiology of common otologic surgical procedures in pediatric patients: A population-based birth cohort study.

OBJECTIVE: It is generally recognized the most common pediatric otologic surgical procedure is ventilation tube insertion (VTI). Tympanoplasty and mastoidectomy are more frequently performed on adults. In this study we examined the incidence and age distribution of these procedures by use of a population-based birth cohort design, in order to provide an overall view of the role of these procedures in the pediatric population. MATERIALS AND METHODS: We used the national health insurance research database in Taiwan. We retrieved data on all patients born in the years 2000 and 2001, subsequently underwent VTI, tympanoplasty or mastoidectomy from 2000 to 2013. The incidence and age distribution of these procedures were analyzed. RESULTS: The cumulative incidence of VTI, tympanoplasty, and mastoidectomy was 0.41%, 0.02% and 0.025%, respectively. VTI were more often performed on children 4 or 5 years of age. Tympanoplasties are frequently done on children older than 5, and 30.7% of them had earlier VTI. The time interval from VTI to tympanoplasty was 5.18 ±â€¯2.27 years (mean ±â€¯SD). Mastoidectomies are more often performed on children from 2 to 9 years of age. CONCLUSIONS: VTI was the most frequent otologic surgery for the pediatric population, and was more often performed on children 4-5 years old. Also, tympanoplasty is more frequently performed on children older than 5, and a third of them had prior VTI. Overall, the time interval from VTI to tympanoplasty was 5.18 years. Furthermore, children with cleft palate and congenital metabolic disorder were more prone to otologic surgical procedures.

Differential effects of postoperative oral corticosteroid on eosinophilic vs. non-eosinophilic CRSwNP subtypes.

PURPOSE: The efficacy of postoperative oral corticosteroids on surgical outcomes in chronic rhinosinusitis with nasal polyps (CRSwNP) patients following endoscopic sinus surgery (ESS) remains controversial. This study evaluated the potential benefits of postoperative oral corticosteroids on surgical outcomes in CRSwNP patients and investigated the differential effects on eosinophilic CRSwNP (ECRSwNP) and noneosinophilic CRSwNP (NECRSwNP). MATERIALS AND METHODS: Patients with bilateral CRSwNP who underwent ESS were enrolled and randomized to receive either oral prednisolone (30 mg/day) or placebo for 2 weeks after surgery. Visual analog scale (VAS) and Sino-Nasal Outcome Test 22 (SNOT-22) scores were chosen as the subjective outcomes, evaluated at preoperative baseline and 1, 3, and 6 months postoperatively. Lund-Kennedy Endoscopic Scores (LKESs) were used as the objective outcome, evaluated at preoperative baseline and at 2 weeks and 2, 3, and 6 months postoperatively. RESULTS: In total, 100 patients with bilateral CRSwNP were enrolled, of whom only 82 completed the 6-month follow-up. The subjective outcomes showed no significant difference at each follow-up points. Of the objective outcomes, the corticosteroid group reporting a trend of improvement in LKESs at 6 months postoperatively (p = 0.05). After stratification by tissue eosinophils, only patients with NECRSwNP (<10 eosinophils/HPF) demonstrated a significant improvement in LKESs at 3 months postoperatively (p = 0.03). CONCLUSIONS: Postoperative oral corticosteroids did not provide additional improvements in VAS and SNOT-22 scores; nevertheless, a trend of LKES improvement was noted at 6 months postoperatively. After stratification by tissue eosinophils, this effect was significant only among NECRSwNP patients at 3 months follow-up.

Changes in the nasalance of vowels within the first week following uvulopalatopharyngoplasty.

We conducted a retrospective study to evaluate the short-term effect of uvulopalatopharyngoplasty (UPPP) on changes in the nasalance of five vowels: /a/, /ε/, /i/, /ɔ/, and /u/. Our study group was made up of 20 patients-15 males and 5 females, aged 16 to 57 years (mean: 37.3 ± 11.5)-who had undergone UPPP as a treatment for mild to moderate obstructive sleep apnea. Nasometry was used to obtain nasalance scores in all patients on the morning of the operation (day 1) and subsequently on day 4 or 5 (mean: 4.5 ± 0.5). Preoperatively, nasalance scores were highest for /i/ (mean: 29.8 ± 12.6) and /a/ (mean: 24.1 ± 10.3). After the operation, nasalance scores for all five studied vowels increased; they were highest for /i/ (mean: 40.7 ± +17.8) and /ε/ (mean: 30.0 ± 10.8). The increases in the nasalance of /i/, /ε/, and /u/ were statistically significant (p < 0.05). Our findings indicate that UPPP has a significant impact on nasalance immediately after surgery.

Multiple analyses of factors related to complications in endoscopic sinus surgery.

BACKGROUND: This study was undertaken to evaluate whether endoscopic sinus surgery (ESS) with a microdebrider had an impact on complication rates, and to facilitate the determination of factors associated with complications in patients who underwent ESS at a tertiary referral center in Taiwan. METHODS: This investigation was a retrospective study and literature review. We analyzed 997 consecutive patients who underwent ESS at Mackay Memorial Hospital in Taipei, Taiwan from January 2006 through February 2010. All data including those of patient medical information, and peri- and postoperative complications were provided by the surgeons involved in patient medical care. We analyzed the complication rates using the following 10 variables by univariate analysis and multivariate logistic regression: sex, age, Lund-Mackay score, polyp grading, previous sinonasal surgery, surgeon skill, adjunctive sinonasal surgery, mesenteric type of anterior ethmoid artery, Keros skull base type, and the use of a microdebrider. RESULTS: Of the 997 patients in our study, 78 (7.8%) had complications. Major complications occurred in five patients (0.5%): two with cerebrospinal fluid rhinorrhea, one with medial rectus muscle damage, and two with retrobulbar hematoma. Minor complications were found in 73 patients (7.3%), which included 32 patients with perioperative estimated blood loss > 15% of the total estimated blood volume, 26 with lamina papyracea damage, two with orbital cellulitis, and 13 with postoperative bleeding. Univariate analysis showed that risk factors related to complication rate were advanced Lund-Mackay scores (scores 19-24), advanced polyp grading (Grades 2 and 3), inexperienced surgeon (resident), and microdebrider usage. However, multivariate analysis revealed that complication rate was linked to advanced Lund-Mackay scores (Scores 19-24), mesenteric type of anterior ethmoid artery, and inexperienced surgeon. CONCLUSION: Overall, the results of our study showed that the ESS complication rate was 7.8%, with risk factors including advanced Lund-Mackay scores (19-24, odds ratio 10.4) and inexperienced surgeon. It was also noted that ESS with a microdebrider had no impact on complication rates, although the presence of a mesenteric type of anterior ethmoid artery proved to be a protective factor.

Upregulation of Caveolin-1 correlate with Akt expression and poor prognosis in NPC patients.

OBJECTIVES: The aim of this study is to investigate the role of Caveolin-1 (Cav-1) in nasopharyngeal carcinoma (NPC) progression and correlated with clinical outcomes. METHODS: We used quantitative real-time PCR (qPCR) to detect the difference in the expression of mRNA level of Cav-1 mRNA in NPC, non-NPC cell lines, and 74 NPC and 29 nontumorous nasopharyngeal mucosa biopsies. Western blotting and immunohistochemistry staining were used to detect the protein expression of Cav-1 in cell lines and biopsy tissues. We collected clinical follow-up data to investigate the association with expression of Cav-1 mRNA. Also, transfection of Cav-1 and suppression by delivery of shRNA against Cav-1 into NPC derived cell lines to analyze its influence in Akt signaling. RESULTS: By use of qPCR, immunohistochemical staining, and western blotting, we found that not only is Cav-1 overexpressed in human NPC tumor cells and NPC-derived cell lines but high Cav-1 mRNA expression is associated with poor overall survival time of NPC patients. Furthermore, phosphorylated Akt expression was enhanced by Cav-1 transfection and suppressed by delivery of shRNA against Cav-1. These data suggested a possible regulatory mechanism of Cav-1 on Akt signaling pathway. We also transfected the Cav-1 construct and shRNA in TW01 cells to prove the effect on Akt protein expression. CONCLUSIONS: Overexpression of Cav-1 is related to poor prognosis in NPC patients, which correlated with Akt signaling pathway. Abrogation of Akt signaling by shRNA-mediated knockdown of Cav-1 decreased malignant properties of tumor cells. These data suggest the potential for Cav-1 as a possible novel therapeutic target in NPC treatment.

The protective effect of adenoidectomy on pediatric tympanostomy tube re-insertions: a population-based birth cohort study.

OBJECTIVES: Adenoidectomy in conjunction with tympanostomy tube insertion for treating pediatric otitis media with effusion and recurrent acute otitis media has been debated for decades. Practice differed surgeon from surgeon. This study used population-based data to determine the protective effect of adenoidectomy in preventing tympanostomy tube re-insertion and tried to provide more evidence based information for surgeons when they do decision making. STUDY DESIGN: Retrospective birth cohort study. METHODS: This study used the National Health Insurance Research Database for the period 2000-2009 in Taiwan. The tube reinsertion rate and time to tube re-insertion among children who received tympanostomy tubes with or without adenoidectomy were compared. Age stratification analysis was also done to explore the effects of age. RESULTS: Adenoidectomy showed protective effects on preventing tube re-insertion compared to tympanostomy tubes alone in children who needed tubes for the first time (tube re-insertion rate 9% versus 5.1%, p = 0.002 and longer time to re-insertions, p = 0.01), especially those aged over 4 years when they had their first tube surgery. After controlling the effect of age, adenoidectomy reduced the rate of re-insertion by 40% compared to tympanostomy tubes alone (aHR: 0.60; 95% CI: 0.41-0.89). However, the protective effect of conjunction adenoidectomy was not obvious among children with a second tympanostomy tube insertion. Children who needed their first tube surgery at the age 2-4 years were most prone to have tube re-insertions, followed by the age group of 4-6 years. CONCLUSIONS: Adenoidectomy has protective effect in preventing tympanostomy tube re-insertions compared to tympanostomy tubes alone, especially for children older than 4 years old and who needed tubes for the first time. Nonetheless, clinicians should still weigh the pros and cons of the procedure for their pediatric patients.

Effect of uvulopalatopharyngoplasty on leptin and endothelial function in sleep apnea.

OBJECTIVES: This study evaluated the effects of uvulopalatopharyngoplasty (UPPP) on serum leptin levels and endothelial function in patients with obstructive sleep apnea syndrome (OSAS). METHODS: Fifteen healthy subjects and 35 patients with moderate to severe OSAS who desired UPPP were prospectively enrolled. The serum levels of leptin and nitric oxide derivative (NOx) from their peripheral blood samples were measured by enzyme-linked immunosorbent assay. All subjects participated in sleep studies, which were repeated 3 months after UPPP in the patients with OSAS. RESULTS: Before UPPP, the patients with OSAS had a higher serum level of leptin and a lower NOx level than did the control subjects. The serum leptin levels in the 17 of the 35 patients with OSAS who were surgical responders decreased from 24.2 ± 6.1 ng/mL before operation to 15.9 ± 6.0 ng/mL after operation. The serum NOx levels in these 17 patients increased from 18.5 ± 7.5 µmol/L before operation to 27.3 ± 8.2 µmol/L after operation. In the 18 patients who were unresponsive to surgery, the serum leptin and NOx levels remained impaired after the UPPP. CONCLUSIONS: Successful treatment of OSAS with UPPP leads to the normalization of serum leptin and NOx levels.

Objective olfactory outcomes after revision endoscopic sinus surgery.

BACKGROUND: Patients who suffer from hyposmia and anosmia report a negative effect on their overall quality of life. Smell disturbance of patients with chronic rhinosinusitis (CRS) can improve after endoscopic sinus surgery (ESS). Although several studies have shown that 50-83% of patients may notice an improvement in olfactory function after ESS, the olfactory improvement after revision ESS (RESS), especially by objective measurements, is still lacking. METHODS: Olfactory function was assessed by the traditional Chinese version of the University of Pennsylvania Smell Identification Test (UPSIT-TC) preoperatively and postoperatively, recorded as smell identification test (SIT) score. Olfactory outcomes from anosmia to hyposmia/normosmia, or from hyposmia to normosmia, were considered as "improvement." Postoperative assessments were divided into two periods: period 1 (P1) is defined as >6 but <12 months postoperatively; period 2 (P2) is defined as >12 but <24 months postoperatively. RESULTS: Thirty-two patients with smell disturbance preoperatively (period 0 [P0]) and confirmed by UPSIT-TC were enrolled into this study. Mean SIT score at P0 was 13.3; mean SIT score at P1 was 18.6; mean SIT score at P2 was 20.4. The presence of nasal polyps blocking the olfactory cleft were associated with better olfaction improvements (p < 0.05) as was the degree of mucosal swelling. The overall improvement rates were 44.8 and 47.8% at P1 and P2, respectively. CONCLUSION: RESS resulted in objective evidence of olfactory improvement in approximately one-half of our cohort over 16 months of follow-up and offers a treatment option for an otherwise poor prognosis condition.

Effects of increased payment for ventilation tube insertion on decision making for paediatric otitis media with effusion.

OBJECTIVE: The National Health Insurance (NHI) in Taiwan raised the physician fee for myringotomy with ventilation tube insertion (VTI) from $61.5 to $117.6 in July 2004. This study aimed to evaluate if the increased payment affected the decision making of physicians. METHODS: This study is a retrospective analysis by using NHI databank in Taiwan. All children less than 12 years old who underwent VTI from 1 July 2003 to 30 June 2006 were included. Waiting time and case numbers before and after the increased VTI payment were compared. The waiting time between public and private hospitals was also examined. RESULTS: From the 7408 cases evaluated, there was no difference in waiting time before and after the raise of VTI payment, and no difference within each year group. The case number of VTI increased significantly after the increase in VTI payment (P < 0.05). The waiting time of VTI performed in private hospitals was shorter than that in public hospitals (P = 0.0001). CONCLUSION: The waiting time of VTI for children with otitis media with effusion (OME) has not been shortened after the increase in VTI payment. Waiting time in private hospitals is shorter than that in public hospitals. Increased payment for VTI has no effect on the physicians' decision making regarding to waiting time for children with OME in Taiwan.

The effects of Vaseline gauze strip, Merocel, and Nasopore on the formation of synechiae and excessive granulation tissue in the middle meatus and the incidence of major postoperative bleeding after endoscopic sinus surgery.

BACKGROUND: Endoscopic sinus surgery (ESS) has become the widely accepted procedure for the treatment of medically refractory chronic rhinosinusitis and nasal polyps. Nasal packing is usually placed after ESS to prevent synechia formation and postoperative bleeding and to support wound healing. The aim of this study was to evaluate the effects of three different nasal packing materials [Vaseline gauze strip, Merocel (Metronic Xomed, Jacksonville, FL, USA), and Nasopore (Polyganics, Rozenburglaan, Groningen, The Netherlands)] on the formation of synechiae and excessive granulation tissue in the middle meatus and incidence of major postoperative bleeding in patients who had undergone ESS. METHODS: A total of 626 patients (1,018 sides) who had undergone ESS were studied retrospectively. Each patient chose one of the three different nasal packing materials according to his or her own preference. The outcome variable was the formation of synechiae and excessive granulation tissue in the middle meatus, which was identified from the medical records of endoscopic evaluations performed 3-4 weeks and 10-12 weeks after surgery. Major postoperative bleeding within 2 weeks after the operation was also documented for analysis. Finally, multiple logistic regression models were used to confirm the results of this study. RESULTS: We did not observe significant intergroup differences in the effect on the formation of synechiae in the middle meatus. Nasopore packing showed a trend toward causing the formation of excessive granulation tissue during the early stages of wound healing (p=0.004). Patients who had received packing with Nasopore had a greater chance of undergoing readmission or additional packing because of major nasal bleeding within the first 2 weeks after the operation (p=0.03). Multivariable logistic regression models showed that Nasopore was a significant factor for the formation of excessive granulation tissue at 3-4 weeks after the operation (p=0.022) and for major postoperative nasal bleeding within the first 2 weeks after the operation (p=0.023). CONCLUSION: Among patients who had undergone ESS for rhinosinusitis with or without polyps, the incidence of synechiae and excessive granulation tissue in the middle meatus and major postoperative bleeding in the patients who received Vaseline gauze packing was equivalent to the incidence of these complications in the patients who received Merocel. Nasopore was not superior to the other two nonabsorbable packing materials.

Effect of uvulopalatopharyngoplasty on endothelial function in obstructive sleep apnea.

OBJECTIVES: This study evaluates the effects of uvulopalatopharyngoplasty (UPPP) on serum levels of nitric oxide derivatives (NO(x)) and endothelial function by endothelium dependent flow-mediated dilation (FMD) in obstructive sleep apnea syndrome (OSAS). STUDY DESIGN: Prospective study. SUBJECTS AND METHODS: Fifteen healthy subjects and 30 subjects with moderately severe to severe OSAS who desired UPPP were prospectively enrolled. FMD was measured by high-resolution B-mode ultrasonography; serum level of NO(x) from peripheral blood samples was also measured. All subjects participated in sleep studies. These studies were repeated 3 months after UPPP in OSAS patients. RESULTS: For healthy patients, there was no difference in serum level of NO(x) and FMD between baseline and 3 months later. The serum levels of NO(x) in 14 of 30 patients with OSAS - designated surgical responders - increased from 13.9 +/- 5.5 microM preoperation to 28.9 +/- 8.2 microM postoperatively. FMD increased from 5.2 +/- 5.0 preoperatively to 10.0 +/- 4.7 postoperatively. For the 16 unresponsive patients, serum NOx and FMD remained impaired after UPPP. CONCLUSION: Successful treatment of OSAS with UPPP leads to restoration of FMD and normal serum levels of NO(x).

Regulation of IAPs gene family by interleukin-1 alpha and Epstein-Barr virus in nasopharyngeal carcinoma.

BACKGROUND: Inhibitors of apoptosis proteins (IAPs), which counteract apoptosis by potently inhibiting caspase activation, are promising targets of new anti-tumor therapy. However, their roles in the pathogenesis of nasopharyngeal carcinoma (NPC), an Epstein-Barr virus (EBV)-associated carcinoma, are not fully understood. Herein, we investigated the expression and regulation of IAPs in NPC. METHODS AND RESULTS: Using real-time quantitative polymerase chain reaction (PCR) analysis, we found that among the IAPs family only the transcription of survivin, HIAP-1, and HIAP-2 was consistently up-regulated in NPC and metastatic NPC tissues. Immunohistochemical staining showed that their proteins were more predominantly expressed in tumor cells nests. Noteworthy, these IAPs were upregulated by interleukin-1 alpha stimulation or EBV infection, and subsequently resulted in triggering rapid proliferation of NPC verified by strong Ki-67 staining. CONCLUSION: Survivin, HIAP-1, and HIAP-2 were distinctly upregulated in NPC, suggesting they may play significant roles in NPC tumorigenesis and serve as tumor markers with prognostic and therapeutic implications.