Imaging Characteristics Predictive of Cervical Extranodal Tumor Extension in Patients With Head and Neck Squamous Cell Carcinoma.

OBJECTIVES: The aims of the study were to determine the predictive imaging findings of extranodal extension (ENE) in metastatic cervical lymph nodes of head and neck squamous cell carcinoma and to investigate the interobserver agreement among radiologists with different experience levels. MATERIALS AND METHODS: Patients with cervical lymph node dissection and who had metastatic lymph nodes and preoperative imaging were included. Three radiologists evaluated nodal necrosis, irregular contour, gross invasion, and perinodal fat stranding. They also noted their overall impression regarding the presence of the ENE. Sensitivity, specificity, odds ratios based on logistic regression, and interobserver agreement of ENE status were calculated. RESULTS: Of 106 lymph nodes (that met inclusion criteria), 31 had radiologically determined ENE. On pathologic examination, 22 of 31 nodes were positive for ENE. The increasing number of metastatic lymph nodes was associated with the presence of the ENE ( P = 0.010). Irregular contour had the highest sensitivity (78.6%) and gross invasion had the highest specificity (96%) for the determination of the ENE. The radiologists' impression regarding the presence of the pathlogical ENE had 39.3% sensitivity and 82% specificity. Metastatic lymph nodes with a perinodal fat stranding and with the longest diameter of greater than 2 cm were found to be strong predictors of the ENE. The gross invasion demonstrated the highest κ value (0.731) among the evaluated imaging criteria. CONCLUSIONS: In the assessment of ENE, the gross invasion had the highest specificity among imaging features and showed the highest interobserver agreement. Perinodal fat stranding and the longest diameter of greater than 2 cm in a metastatic lymph node were the best predictors of the ENE.

Management and long-term comorbidities of patients with necrotizing otitis externa.

PURPOSE: We aimed to present the management of the patients with necrotizing otitis externa (NOE) and its comorbidities in early and long-term follow-up. METHODS: Between 2011 and 2022, 30 patients with the diagnose of NEO, who had cortical bone erosion or trabecular demineralization in temporal bone computed tomography and administered at least 6-week antimicrobial therapy were included in the study. Clinical, laboratory and imaging findings of patients, and comorbidities during follow-up were analysed. NOE extending further from the petro-occipital fissure on magnetic resonance imaging was accepted as medial skull base (MSB) involvement. RESULTS: 30 patients, (8 women, 22 men, mean age 66.2 ± 1.7), with NOE were followed 36.4 ± 29.6 months. The mortality rate was 23.33% and the mean survival time was 12.37 ± 11.35 months. Repeated cultures reveal a new or second pathogen in 5 patients (20%). Severe and profound sensorineural hearing loss (SNHL) were observed in 4 and 12 patients, respectively. Labyrinthitis ossificans emerged in 3 of 6 surviving patients with profound SNHL during follow-up. Chronic disease anemia (CDA) (66.66%), cerebrovascular disease (CVD) (43.33%), chronic renal failure (CRF) (30%), and retinopathy (26.66%) were the most frequent comorbidities in patients with NOE. Cranial nerve paralysis (CNP) (P < 0.001), SNHL (P < 0.04), CDA (P < 0.005), and mortality (P < 0.022) were significantly associated with the presence of MSB involvement. CONCLUSIONS: NOE is a disease that requires long-term follow-up, causes severe morbidity, and has a high mortality rate. MSB involvement is associated with CNP, SNHL and labyrinthitis ossificans. Moreover, CDA, CVD, CRF and retinopathy are the most common comorbitidies needed to be managed.

A Huge Oropharyngeal Pyogenic Granuloma in a Patient Presenting with Dysphagia.

A 39-year-old woman experienced dyspnea and progressive dysphagia for 1 year. Dysphagia appeared for solid foods at the beginning but advanced for liquids. She described 17 kg weight loss in the past 6 months and her current weight was 38 kg [body mass index (BMI) 16 kg/m2]. Dyspnea presented with effort and lying was included after 1 month. There was no disease or surgery except chronic hepatitis C in her medical history. Physical examination revealed hyponasal speech and a mass beside the tongue base. A smoothly surfaced 4 × 3-cm vascular mass in oropharynx was determined in endoscopic examination. The mass was mobile and occupied 80% of oropharyngeal area. Contrast-enhanced computed tomography revealed hypervascular 4 × 4 × 3 cm pedunculated (8 × 13 mm) mass arising from the right tongue base. The mass and the surrounding mucosa with a thin layer of tongue musculature were excised using cold instrumentation and bipolar cautery. Histologically the mass was reported as pyogenic granuloma (PG). This is the first study to report on oropharyngeal PG causing obvious weight loss in literature.

The effect of anatomic variations and maxillary sinus volume in antrochoanal polyp formation.

PURPOSE: The antrochoanal polyp (ACP), otherwise known as the Killain polyp, is a benign lesion that originates from maxillary sinus mucosa, extending from the accessory ostium towards the middle meatus, and later tends to protrude posteriorly towards the choana and nasopharynx. Many studies have emphasized that its etiopathogenesis is unclear. Research suggests that chronic sinusitis and allergic rhinitis are factors that play an important role in the formation of ACP, as well as anatomical variations. In this study, we aimed to evaluate the effect of anatomical variations and maxillary sinus volume in patients diagnosed with anthrochoanal polyp. METHODS: Paranasal sinus computed tomography (PNS CT) images of patients with unilateral ACP patients were examined. The non-ACP sides of the patients comprised the control group. Nasal septal deviation, agger nasi cells, concha bullosa, paradoxical middle turbinate, hyperpneumotized ethmoid bulla, uncinate pathology (medialized or pneumatized uncinate), haller cell, accessory ostium, maxillary sinus retention cyst and maxillary sinus volumes were evaluated. RESULTS: The study included a total of 54 patients (33 females, 21 males). Mean patient age was 22.92 ± 13.95 (range 6-56) years. Mean maxillary sinus volume was 17.88 ± 5.16 mm3 for the ACP sides and 16.37 ± 4.55 mm3 for the non-ACP sides. Maxillary sinus volume was significantly larger in the ACP side (p = 0.000). Concha bullosa was observed on the ACP side in 23 patients (42.6%) and in the non-ACP side in 21 patients (38.9%). Agger nasi cells were observed in the ACP side in 47 patients (87.0%) and in the non-ACP side in 42 patients (77.7%). Hyperpneumatized ethmoid bulla was observed in the ACP side in 14 patients (25.9%) and in the non-ACP side in 12 patients (22.2%). Haller cells were observed in the ACP side in seven patients (12.96%) and in the non-ACP side in ten patients (18.51%). CONCLUSION: Disrupted airflow of the well-developed maxillary sinus cavity due to anatomical variations seems to be an effective factor in the formation of ACP.

Relationship Between Lacrimal Bone Thickness and Lacrimal Sac in Chronic Dacryocystitis.

BACKGROUND: Chronic inflammation in the lacrimal sac may lead to thickening of the surrounding bony tissues. This study aimed to assess the thickness of lacrimal bone surrounding the lacrimal sac, and the thickness of maxilla, based on the presence of purulent secretion in the lacrimal sac in patients who underwent EDCR. MATERIAL AND METHODS: Lacrimal bone thickness and the maximum and midpoint maxillary bone thickness of 70 patients (mean age of 49.07 years) who underwent EDCR, were assessed along 3 planes (upper, middle, and lower) using CT of the paranasal sinus. The patients were divided into 2 groups: the 1 who had purulent secretion in the lacrimal sac during the intraoperative period (Group 1) and another who did not have purulent secretion (Group 2). RESULTS: No significant difference was detected between the 2 groups in terms of maximum and midpoint maxillary bone thickness. The increase in the thickness of lacrimal bone in Group 1 was statistically significant in all the 3 planes as compared to that in Group 2. Cutoff values for the thickness of the upper, middle, and lower plane of lacrimal bone were detected to be 0.710 mm, 0.685 mm, and 0.675 mm, respectively. CONCLUSION: The presence of purulent secretion in the lacrimal sac, along with the detected increase in the thickness of the lacrimal bone, as assessed by CT, offers an insight on the lacrimal sac before the surgery.

Comparison of Piezosurgery and Hammer-Chisel in Endoscopic Dacryocystorhinostomy.

BACKGROUND: In this study, we compared the advantages and disadvantages of piezosurgery and hammer-chisel used in endoscopic dacryocystorhinostomy (EDCR). MATERIAL AND METHODS: Between January 2012 and January 2016, 10 women and 8 men in whom piezosurgery was used (group 1) and 11 women and 7 men in whom hammer-chisel was used (group 2) during EDCR operations were compared retrospectively. Recurrence, operation time, postoperative bleeding, and operative cost were evaluated in patients who were followed for an average of 11.8 months. In addition, visual analogue scale (VAS) was used to assess pain at 6 hours postoperatively. RESULTS: No recurrence was observed in group 1, but recurrence was observed in 2 patients in group 2 (P = 0.685). There was no postoperative bleeding in both groups. The mean duration of operation was 30.6 ±â€Š8.2 minutes in group 1 and 46.8 ±â€Š9.5 minutes in group 2 (P = 0.038). The VAS score in group 1 was 2.7 ±â€Š1.4 and the VAS score in group 2 was 5.8 ±â€Š2.2 (P = 0.01). Piezosurgery costs an additional $325 for each patient while the use of the hammer-chisel does not incur additional costs. CONCLUSION: Piezosurgery causes shorter operation time, less recurrence, and less pain when compared with hammer-chisel.

Prognostic factors of recurrence and neck metastasis in oral carcinomas.

OBJECTIVE: To assess the effects of tumor size, proximity to midline and invasion depth of oral cancer of the tongue (TC) on neck metastasis and recurrence. METHODS: In this retrospective observational study, was conducted through a chart review of the 11 male and 9 female patients who underwent surgeries with the diagnosis of tongue squamous cell carcinoma and at least one side neck dissection. We wanted to assess effects of tumor size, proximity to midline, and invasion depth of TC, according to the surgical specimens and pre-operative magnetic resonance imaging, on neck metastasis and recurrence between 2007 and 2014. The study was conducted in a training hospital-based otorhinolaryngology clinic. Statistical analyses were performed to determine possible relationship between such tumor features and tumor recurrence and neck metastasis. RESULTS: Statistically significant relationship were detected between recurrence and the proximity of tumor to midline (p=0.031) and between invasion depth and neck metastasis (p=0.017). No relationship was found between tumor size and recurrence and neck metastasis (p=0.721 and p=0.827, respectively). CONCLUSIONS: Parameters like invasion depth and tumor proximity to midline might provide useful information about prognosis and may help to determine a treatment schedule in patients suffering fdrom cancer of the tongue. The present TNM classification might not be sufficient to provide enough information to determine prognosis and staging adequately in these patients.

Bacterial change in external auditory canal upon antisepsis with povidone-iodine during tympanoplasty.

The aim of this single-arm prospective study was to determine the flora of the external auditory canal (EAC) in inactive chronic otitis media and evaluate the alteration of microorganisms of the EAC during tympanoplasty upon povidone-iodine antisepsis. Sixty-three patients with central tympanic membrane perforation were enrolled in the study. Preoperative swab cultures were obtained and the EAC was packed with povidone-iodine absorbed gauze. Type I tympanoplasty via a retroauricular route was performed. Cultures from the EAC were taken at the end of each operation. Isolated organisms were identified based upon microbiological, morphological, and biochemical characteristics. The most commonly isolated organisms from preoperative samples were normal commensal flora, including 73 coagulase-negative staphylococci (CNS) and 18 diphtheroid bacilli (DB). Less commonly cultured pathogenic species included four isolates of Staphylococcus aureus and three isolates of Candida albicans. No bacteria were observed in five patients. Following povidone-iodine antisepsis, 32 of the samples were negative. Eradication was statistically significant for CNS, DB and pathogen microorganism (P < 0.05). Isolated bacteria differed from those in preoperative swab cultures in eight cases. After antisepsis, diverse strains of the CNS were isolated in 13 cases and 10 patients showed no change in microbial flora. Postoperative culture demonstrated that all seven pathogenic isolates were eradicated (100 %); this selective efficacy of povidone-iodine antisepsis against pathogenic isolates was significant when compared with commensal flora (P < 0.05). These results suggest that povidone-iodine antisepsis of the EAC before tympanoplasty is an effective method for the elimination microorganisms, especially pathogenic bacteria.

Recurrent meningitis and frontal encephalocele as delayed complications of craniofacial trauma.

Frontal sinus back table fractures are seen rarely; also, typical presentation of frontal sinus encephalocele as a delayed complication of frontal sinus fracture is seen more rarely. We present a case of frontal encephalocele and recurrent meningitis as delayed complications of craniofacial trauma. Diagnosis, management, and treatment approaches of these complications are discussed.

Huge congenital haemangioma of the tongue.

Haemangiomas, the most common type of benign vascular tumours, are rare in the oral cavity. Some of these lesions are congenital and show symptoms in late childhood or early adult life. A 32-years-old woman presented with a huge lesion on her tongue which caused dysphagia and dysphasia. She had first noticed the lesion when she was 6. Her obstructive symptoms started when she was 28 and, despite various medical treatments, the size of the lesion gradually increased. Magnetic resonance imaging revealed a 7 x 5 x 3 cm mass on the right side of the tongue. Because of severe functional and cosmetic problems, the lesion was excised with partial haemiglossectomy. Histopathological examination was consistent with intramuscular haemangioma. Haemangiomas are benign tumours with a benign course and are rarely seen on the tongue. They have clinical importance when localised in the oral cavity. Different treatment modalities exist, but in cases of large tumours, surgery may be the mainstay treatment.

Squamous cell carcinoma originating from the nasal septal perforation: a rare nasal tumor.

Primary squamous cell carcinoma of the nasal septum is an extremely rare malignancy. In this article, we report a case of 52-year-old female with a complaint of nasal obstruction along with occasional nasal bleeding for one year. Endoscopy showed a 2.5x2 cm perforation originating from the anterior nasal septum. Incisional biopsy result was reported as squamous cell carcinoma. The tumor was removed by functional endoscopic surgery. Histopathological examination revealed squamous cell carcinoma with safe surgery borders. No recurrence and complications were noticed after one year of follow-up. The functional impact of the treatment with high mortality rates highlights the importance of early diagnosis. We recommend the differential diagnosis of septal perforation and early wide surgical excision for such cases.

Effects of Anatolian Propolis and Hypertonic Saline Combination Nasal Spray on Allergic Rhinitis Symptoms: A Prospective, Multicenter Study.

Objectives: This study aimed to evaluate how Rhinapi nasal spray affects symptoms of allergic rhinitis. Methods: In this prospective, multicenter, observational study, 10,000 patients (comprising 5028 males and 4972 females) exhibiting symptoms of allergic rhinitis (namely, nasal discharge, sneezing, nasal itching, and nasal obstruction) from different centers in different regions of Turkey were enrolled in the study between March 2022 and March 2023. All the patients wanted to participate in the study and were administered Rhinapi one puff to each nostril three times a day, for a period of 3 weeks. Total symptom scores, quality of life (QoL) scores, and otolaryngological examination scores were evaluated before and 3 weeks after treatment. Results: The scores for discharge from the nose, sneezing, nasal pruritus, and blockage of the nose all indicated improvement when compared to pre-medication and post-medication. This difference achieved statistical significance (P < .001). The mean total symptom score fell following treatment (P < .001): whilst the score was 11.09 ± 3.41 before administering Rhinapi; after administration, the average score was 6.23 ± 2.41. The mean QoL scores also altered after medication (P < .001), improving from a mean value of 6.44 ± 1.55 to a mean of 7.31 ± 1.24. Significant improvement was also noted in the scores for conchal color and degree of edema after the treatment had been administered (P < .001). Conclusion: The study demonstrates that Rhinapi nasal spray decreases total symptom scores, and results in improved QoL and otolaryngological examination scores. Propolis spray may be recommended for patients with allergic rhinitis alongside other treatments.

Endoscopic dacryocystorhinostomy: outcomes using mucosal flap preserving technique.

Currently, transnasal approaches are preferred widely for treating chronic dacryocystitis. Restenosis which count for the most common causes of failure in endoscopic dacryocystorhinostomy (EDCR) reduces the success rate. We intended to make a large fistula, potentially minimizing granulation tissue, and synechiae by means of creating a large bony ostium and preserving mucosal flaps and intubation with silicone tube (STI). In this study, long-term follow-up results of EDCR with mucosa preservation were discussed. 126 patients underwent endonasal DCRs from January 2004 to March 2009. A large ostium was created preserving mucosa; nasal and lacrimal flaps were approximated and the new ostium was stented with silicone tube. Surgical success rate was 93 % with STI and with preservation of nasal and lacrimal flaps. In conclusion, EDCR is an easy surgical procedure with low complication rates. Intranasal pathologies can also be corrected in the meantime. Success depends on creating a large bony ostium and preventing restenosis. EDCR preserving nasal and lacrimal flaps with STI is recommended as an alternative procedure in chronic dacryocystitis with high success rates.

[Long-term results of transnasal radiofrequency in patients with obstructive sleep apnea syndrome]. / Obstrüktif uyku apnesi sendromu olan hastalarda transnazal radyofrekansin uzun dönem sonuçlari

OBJECTIVES: This study aims to investigate the long-term effects of radiofrequency thermal ablation (RFTA) performed to the inferior concha on snoring, apnea index, and daytime sleepiness symptoms in patients who presents with the complaint of snoring and mild obstructive sleep apnea syndrome (OSAS). PATIENTS AND METHODS: Between March 2009 and May 2011, 50 patients (29 females, 21 males; mean age 40.7 years; range 19 to 64 years) who had witnessed sleep apnea and diagnosed with mild OSAS as assessed by polysomnographic analysis in our clinic were included in the study. Twenty-five patients with the history of witnessed sleep apnea underwent sleep analysis using conventional polysomnography (PSG), while portable PSG device was used in other 25 patients. During the follow-up visits, all patients who underwent tissue ablation using RF were assessed by the baseline examination method. Following the polysomnographic analysis, RFTA was performed to the inferior concha of all patients. RESULTS: The mean follow-up period was 18.7 months (range 6-26 months). In the group who underwent conventional PSG, the mean pre-treatment apnea-hipopnea index (AHI) was 11.356±2.9841, while the mean post-treatment AHI was 9.93±2.822. In the group who underwent portable PSG, the mean pre-treatment AHI was 9.196±3.2696, whereas the mean post-treatment AHI was 8.04±3.241. In two patients (4%), inferior concha ulceration was detected. CONCLUSION: Radiofrequency used in the treatment of mild OSAS results in better patient compliance and post-treatment patient comfort, as well as lower post-treatment morbidity and complication rate, compared to conventional surgical techniques.

A comparison of histopathological results of conventional surgery and transoral radiofrequency ablation in early stage laryngeal carcinoma.

OBJECTIVES: This study aims to compare histopathological results of conventional surgery and transoral radiofrequency ablation in patients with early stage laryngeal carcinoma. PATIENTS AND METHODS: Between January 2006 and May 2010, 36 patients (34 males, 2 females; mean age 61.6 years; range 43 to 77 years) who underwent partial laryngectomy in our clinic were retrospectively analyzed. All patients were randomized to partial laryngectomy with radiofrequency ablation or conventional surgery. Hoarseness due to early stage T1 and selected T2N0 vocal cord lesions was an indication for surgery. Of 20 patients receiving conventional surgery, 14 underwent partial laryngectomy, while six patients underwent cordectomy for the excision of tumors. Tumors were excised by transoral radiofrequency ablation in 16 patients. RESULTS: We observed thermal artifacts in four patients undergoing conventional surgery and in 13 patients undergoing transoral radiofrequency ablation. There was also hemorrhage in 16 patients undergoing conventional surgery and in seven patients undergoing transoral radiofrequency ablation. Histopathological examination revealed that the surgical margins were safe in 10 patients after radiofrequency ablation. The specimens obtained from six patients showed thermal artifacts which complicated histopathological examination. Sixteen (80%) of 20 conventional surgery patients and nine (56%) of 16 radiofrequency ablation patients had safe surgical margins. CONCLUSION: In radiofrequency ablation, the surgical zone must be larger than in conventional surgery due to the high risk of tissue damage and complicated histopathological examination.

The Impact of the COVID-19 Pandemic on Urgent Awake Tracheotomies in Adults.

Objective This study aims to investigate the impact of the COVID-19 pandemic on urgent awake tracheotomies (UATs) in adults in a reference center. Methodology During the pandemic (between March 2020 and May 2022) and before the pandemic (between January 2018 and March 2020), medical charts of patients who underwent UATs were reviewed. The analysis focused on demographic characteristics, indications, COVID-19 positivity status, surgical procedures, and complications. Results During the pandemic, 67 UATs (age 62.04 ± 11.9 years) were performed. Of the indications, 56 (83.5%) were malignancy. Before the pandemic, 22 UATs (age 63.86 ± 15.1 years) were performed, of which 14 UATs (63.6%) were due to malignancy. There was a significant increase in UATs and their indications in patients with head and neck malignancies (P < 0.05). Stay suture (65, 97%) and suture ligation of the thyroidal isthmus (61, 91%) were significantly performed during the pandemic (P < 0.05). Conclusions A significant increase in UAT was detected, especially in patients with advanced head and neck cancer. Pandemic conditions and the risk of viral transmission have led to more conservative UAT techniques.

Relationship of E-cadherin, Beta-catenin, N-cadherin, ZEB1 and αSMA as Epithelial Mesenchymal Transition markers with prognostic factors in early and advanced stage laryngeal squamous cell carcinomas.

Aims: To investigate the relationship between E-cadherin, beta-catenin, N-cadherin, ZEB1, and αSMA as epithelial-mesenchymal transformation markers with tumor stage, lymph node metastasis (LNM), and overall survival (OS) in laryngeal squamous cell carcinomas (LSCC). Materials and Methods: A total of 100 cases diagnosed with LSCC were included in the study. Data about the lymphovascular invasion (LVI), perineural invasion (PNI), necrosis, and LNM were recorded by evaluating hematoxylin-eosin-stained slides. Markers of E-cadherin, beta-catenin, N-cadherin, ZEB1, and αSMA were applied to the sections prepared from paraffin blocks of tumor samples. Results: Ninety-five male and five female patients were included in the study, and 38 of them exited. A significant relationship was observed between OS with advanced tumor stage, presence of LNM and PNI. A significant relationship was found between increased tumor Zeb1 expression and advanced tumor stage. In univariate and multivariate analyses, a significant negative relationship with OS, and increased Zeb1 expression in tumor and tumor stroma was seen. Any relationship was not observed between E-cadherin, beta-catenin, N-cadherin, and αSMA and OS. Conclusion: Among the EMT markers, we evaluated in our study, it was seen that Zeb1, which is an EMT transcription factor, is associated with tumor stage, LNM, and OS. Remarkably, Zeb1 expression observed in tumor stroma was also significant for OS. Any similar data reported for LSCCs have not been encountered in the literature, and it was thought that it would be appropriate to support our findings with further studies to be performed on this subject.

[Anatomical and functional results of open cavity tympanomastoidectomy]. / Açik kavite timpanomastoidektominin anatomik ve fonksiyonel sonuçlari

OBJECTIVES: In this study, we aimed to evaluate the anatomical and functional results of open cavity tympanomastoidectomy due to chronic otitis media with cholesteatoma. PATIENTS AND METHODS: Between January 2003 and October 2009, 166 patients who underwent open cavity tympanomastoidectomy due to chronic otitis media with cholesteatoma in our clinic were retrospectively analyzed. Seventy-two ears of 69 patients (40 males, 29 females; mean age 36.7±17.7 years; range 9 to 64 years) who visited on a regular basis due to acquired middle ear cholesteatoma were included. Cholesteatoma was classified as attic, sinus and tensa retraction cholesteatoma, according to its localization. Audiological findings were compared based on the localization of cholesteatoma and intraoperative ossicular status. RESULTS: The mean follow-up was 36.3±27.0 months (range 6 to 88 months). There were six (8.4%) greft failures, four (5.6%) graft retractions, and one (1.4%) recurrent cholesteatomas in the ears of the patients. There were also five (7%) pearly residual cholesteatomas. At the last visit following surgery, 97.2% of cavities were dry and self-cleaning. The mean preoperative pure tone air threshold was 53.5±22 dB, while it reduced to 52.2±23.3 dB at the last visit in 48 ears operated open cavity tympanomastoidectomy type 1, 2, 3, and 4 in combination with hearing reconstruction (p=0.454). There was a statistically significant reduction in the mean air-bone gap of the attic cholesteatomas, decreasing from 27.2±14.6 dB to 21.6±12.2 dB (p=0.007). Air-bone gap values were lower than 20 dB in 23 (47.9%) of the cases and the gain was more than 10 dB in 17 (35.5%). No statistically significant correlation was found between the localization of cholesteatoma and intraoperative ossicular status (p>0.05). CONCLUSION: Open cavity tympanomastoidectomy, which allows total removal of the pathology, is an applicable surgical approach with satisfactory outcomes for hearing reconstruction.

Wegener granulomatosis presenting as refractory otitis media: a case report.

Wegener's granulomatosis (WG) is a granulomatous widespread necrotizing vasculitis, sometimes progressing rapidly, characterized by a tendency to involve the upper and lower respiratory tracts, and in most cases, the kidneys. Otologic manifestations may be seen during the course of the disease, however, they are not frequently seen as the first and only presenting feature. The presence of anticytoplasmic antibodies versus neutrophil polymorphonucleate granules (c-ANCA) is highly specific for the diagnosis of WG, being positive in 97% of the cases. The early diagnosis and the timely medical treatment result in high rates of remission of this potentially lethal disease. In this article, we report a case of WG presenting with acute serous otitis media, progressing to suppurative otitis media and granulomas as the first and only symptom, which was refractory to medical therapy during follow-up and which was diagnosed with further examination.