A novel diagnostic method for myasthenia gravis.

INTRODUCTION/AIMS: Videonystagmography (VNG) which directly records eye movements using infrared video goggles with mini-cameras, is used to measure nystagmus. Our aim is to explore whether VNG can be used to detect a decrement in the extraocular muscle (EOM) activity of patients with myasthenia gravis (MG). METHODS: Thirty-four patients with MG, including 13 with ocular-predominant and 21 with generalized MG, and 23 healthy controls participated. Using VNG we recorded the velocity of the eye movements of the patients as they followed a moving target. We then calculated the gain by dividing the eye movement velocity (degrees/second) by the target velocity (degrees/second). RESULTS: In MG subjects, the mean initial gain (maximum gain) was 1.23 ± 0.31 (range: 0.63-2.15) for the right eye and 1.22 ± 0.37 (range; 0.60-2.28) for the left eye. The mean minimum gain was 0.11 ± 0.12 (0.01-0.58) for the right and 0.14 ± 0.5 (0.02-0.55) for the left. Due to fatigue, the movement gain was reduced by 91.7% in the right eye and 88.2% in the left eye. After reaching minimum velocity, gain remained at a minimum for a mean of 1.08 ± 0.52 (0.3-2.4) s for the right and 1.49 ± 0.85 (0.4-3.6) s for the left, before the velocity increased again. There was no fatigue-induced decrement in healthy subjects. DISCUSSION: Our study documents a decrement in EOM activity recorded by VNG in patients with MG which begins to improve within 1-2 s after reaching minimum velocity, analogous to traditional low-frequency repetitive nerve stimulation testing and its U-shaped pattern. Thus, VNG may be a promising diagnostic test for MG.

The investigation of hyaluronic acid and hyaluronidase-1 levels as tumour marker in larynx cancer.

OBJECTIVE: The purpose of this study was to investigate the hyaluronic acid (HA) and hyaluronidase-1 (HYAL-1) levels in laryngeal cancer patients. STUDY DESIGN: Prospective, controlled clinical trial. SETTING: University Medical Center. PARTICIPANTS: Fifty laryngeal squamous cell carcinoma patients and 50 volunteers who gave saliva samples investigated prospectively between 2016 and 2017. METHODS: Hyaluronidase-1 expression was measured by RT-PCR in normal and tumour tissue samples; hyaluronic acid values of saliva and tumour tissues were measured by ELISA method. RESULTS: HYAL-1 expression increased 2.5-fold in tumour tissues compared to normal tissues, and the difference was statistically significant (P < 0.001).Mean saliva HA levels were 103.93 ± 69.04 ng/mL and 177.29 ± 98.44 ng/mL in the patients and controls' saliva specimens, respectively. The difference was not statistically significant (P = 0.657). HA levels were higher in tumour tissue samples than saliva samples, but there was not statistically significant difference between saliva and tumour tissue HA levels. CONCLUSION: HYAL-1 expression in laryngeal squamous cell carcinomas is elevated compared to normal tissues of same patients. Targeting this gene and HA catabolism products may use treatment of larynx cancer in the future.

A Rare Cause of Objective Tinnitus: Jugular Diverticulum.

The jugular bulb is a venous structure linking the sigmoid sinus with the internal jugular vein. Jugular diverticulum is a rare condition characterized by extraluminal outpouching from the jugular bulb. As the patients may be totally asymptomatic, but sensorineural symptoms such as sensorineural hearing loss, tinnitus and vertigo can also occur. Diagnosis of these patients can be made by some radiologic methods such as high-resolution computerized tomography, magnetic resonance imaging, or a novel radiologic technique flat panel computed tomography. In this paper we report a 22-year-old female patient with jugular diverticulum presenting with tinnitus complaint.

Effectiveness of transcranial magnetic stimulation application in treatment of tinnitus.

OBJECTIVE: Pathophysiology of tinnitus known to accompany nearly all disorders in hearing system has not been fully understood, and therefore, there are some difficulties in evaluation and treatment thereof. The objective of the current study is to research the effectiveness of transcranial magnetic stimulation (TMS) application in treatment of tinnitus. MATERIALS AND METHODS: Sixty patients aged between 15 and 70 years who applied to a polyclinic of Ear-Nose-Throat Department, Cerrahpasa Medical Faculty, Istanbul University, because of the complaint of tinnitus between January 2009 and July 2009 were selected using simple random sampling method. The treatment group and the placebo group were separated randomly as to include 30 patients. The tinnitus loudness, tinnitus frequency, tinnitus subjective score, and tinnitus handicap inventory results were compared before application of TMS and after 1 month. FINDINGS: It was found that the difference of tinnitus handicap inventory score within the TMS group (before the treatment: mean, 52.76; SD, 15.8; after the treatment: mean, 44.4; SD, 13.57) was statistically significant (P < 0.0001) and the difference of tinnitus handicap inventory score within the placebo group (before the treatment: mean, 51.46; SD, 15.41; after the treatment: mean, 51.13; SD, 16.86) was significantly insignificant (P = 0.848). When tinnitus severities determined at the beginning and end of the treatment were evaluated within each group, it was found that the difference of loudness within the group subjected to TMS was statistically significant (P < 0.0001) but the difference of loudness within the placebo group was statistically insignificant (P = 0.490). When tinnitus subjective scores were evaluated within each group before and after the treatment, the difference of subjective score within the group subjected to transcranial magnetic stimulation was statistically significant (P < 0.0001), and the difference of subjective score within the placebo group was statistically significant (P = 0.168). CONCLUSIONS: The studies showed that low-frequency repeating TMS is useful in the treatment of chronic tinnitus. In the current study performed on the patients with chronic tinnitus, it was shown that low-frequency repeating TMS has a statistically significant success when compared with the placebo group.

Laryngeal foreign body mimicking croup.

Foreign body aspiration can be a fatal problem in all groups of ages. However, it is a leading cause of accidental deaths in children. Especially in the pediatric age group, diagnosis can be delayed because of various challenges. Children younger than 3 years carry the highest risk, as they are inclined to explore objects with their mouths. In most cases of inhaled foreign body, a positive history of aspiration is obtained. We are reporting a case of laryngeal foreign body that is mistreated for 1 week as a croup syndrome.

Prognosis and risk factors for early-stage adenoid cystic carcinoma of the major salivary glands.

BACKGROUND: Adenoid cystic carcinoma (ACC) is characterized by slow growth, frequent local recurrences, and distant metastasis (DM). However, these findings frequently are reported in patients with advanced-stage tumors, but the outcomes of early-stage tumors are poorly defined. We sought to evaluate the risk factors for the development of DM in early-stage ACC. METHODS: We retrospectively reviewed the charts of 60 patients who were diagnosed with clinical early-stage (T1-2/N0) ACC to determine the risk factors for development of DM and survival of these patients. RESULTS: DM was detected in 12 (20%) of the patients, with a median latency of 31.5 months after diagnosis. Univariate analysis revealed that DM was associated with age ≥45 years, pathologically positive lymph nodes, extracapsular spread (ECS) from lymph nodes, high-grade histology, and solid tumor subtype. Multivariate analysis revealed solid tumor subtype and ECS to be significantly associated with DM. Disease-specific survival rates at 5 and 10 years for patients with DM were 80% and 40%, respectively, and were both 100% for patients without DM. CONCLUSION: Although the majority of patients with clinical early-stage ACC of the major salivary glands have favorable prognosis, a significant percentage of patients will develop DM. Solid tumor subtype and nodal ECS were independent predictors of DM in early-stage ACC of major salivary glands. Other clinical and pathological variables may also contribute. These subgroups had poor overall and disease-specific survival. Such patients should be observed closely for the development of DM. Systemic therapy should be considered at the time of diagnosis.

Use of titanium mesh in laryngotracheal reconstruction: an experimental study on rabbits.

Titanium mesh may be an alternative material to be used in laryngotracheal reconstruction. Twenty New Zealand rabbits were divided into two groups. Group A underwent laryngotracheoplasty with titanium mesh-buccal mucosa-muscle complex, and Group B received auricular cartilage grafts. All animals survived without complications. The animals were killed at 60 days, and laryngotracheal regions were evaluated. There was no subglottic collapse at physiologic and supraphysiologic negative airway pressures in Group A and mild-moderate collapse in Group B. Macroscopically the average antero-posterior and lateral diameters were not statistically different among two groups. Light microscopic examination revealed no fibrosis, necrosis or new cartilage formation in both groups. Inflammation and granulation were more pronounced in Group A. The lumens in both groups were moderately obstructed. Reconstruction of the upper airway with titanium mesh may be used in very selected cases where autologous grafting materials are inadequate and unsatisfactory.

Adjuvant use of liquid alginate suspension for post-tonsillectomy morbidity: double-blind randomized clinical trial of efficacy.

OBJECTIVE: To evaluate the efficacy of liquid alginate suspension in alleviating post-tonsillectomy morbidity in adult patients. METHODS: A prospective, double-blind, randomized, placebo-controlled study comparing the effect of liquid alginate suspension with placebo was performed on 40 patients who underwent tonsillectomy at Derince State Hospital, Kocaeli, Turkey. The patients were randomly chosen, and each used liquid alginate suspension four times daily or a placebo solution at the same regimen. Tonsillectomy was performed under general anesthesia by cold dissection and suture ligation. Patients were examined at postoperative days 1, 3, 5, and 7 for healing, instructed to note the amount of analgesics used, and asked to mark the visual analog score of throat pain every day for a week. RESULTS: The study group had statistically significant lower pain scores at day 2 (P = 0.03). Study group required less analgesic than the control group during the study period, but the difference was statistically different only on day 2 (P = 0.003) day. Healing was statistically significant on day 5 (P = 0.03) in the study group. CONCLUSION: Use of the antireflux suspensions in patients undergoing tonsillectomy may be effective in reducing postoperative morbidity in adjunct with classic analgesics.

Detection of laryngeal tumors and tumoral extension by multislice computed tomography-virtual laryngoscopy (MSCT-VL).

Virtual endoscopy is becoming a widely used non-invasive clinical diagnostic tool. The present study was designed to compare the sensitivity and specificity of the conventional endoscopy and virtual laryngoscopy with respect to laryngeal masses. A total of 38 patients (20 males, 18 females, mean age 61 years) with the complaint of hoarseness were included in the study. Laryngeal mucosa, lumen and mass pathology were evaluated initially by direct endoscopy and then by virtual laryngoscopy during multislice CT of the larynx. Histopathologic evaluation of the masses was also made. The main pathology of the patients was found to be laryngeal masses (60% of patients, one mass for each patient), which were polyps (n = 8), papilloma (n = 4) and carcinoma (n = 11) according to histopathologic evaluation. Retrospective evaluation of 6 lesions detected in virtual but not in conventional laryngoscopy resulted with the finding of viscous-dense mucous secretion. On the contrary, three lesions detected by conventional laryngoscopy could not be detected by virtual evaluation. A total of six patients were evaluated and considered as normal both by conventional and virtual laryngoscopic examinations. Sensitivity of the virtual laryngoscopy was 88% (23/26) while its specificity was only 50% (6/12). Positive and negative predictive values were 79% (23/29) and 66% (6/9), respectively. Accuracy of the virtual laryngoscopy was 76% (29/38). Virtual laryngoscopy is not an alternative to conventional laryngoscopy but may assist direct endoscopy without causing additional radiation exposure or discomfort to the patient. The three-dimensional contribution to interpretation of the results and subsequent manipulation of the data can be used for educational and surgical purposes.

Closure of Orocutaneous Fistula Using Submandibular Gland as a Pedicled Flap.

Orocutaneous fistulas in the maxillofacial region may be due to tumor resection, osteoradionecrosis, or trauma, and these defects limit the function of the patients and effect aesthetic and also psychological condition. Articulation and nutrition are also affected by these fistulas. Local flaps can be used for the reconstruction of small- and medium-sized defects with ease. Submandibular gland with its rich blood supply from the facial artery is a practical and useful choice for the reconstruction of mandibular region defects.

Decellularization of Trachea With Combined Techniques for Tissue-Engineered Trachea Transplantation.

OBJECTIVES: The purpose of this study is to shorten the decellularization time of trachea by using combination of physical, chemical, and enzymatic techniques. METHODS: Approximately 3.5-cm-long tracheal segments from 42 New Zealand rabbits (3.5±0.5 kg) were separated into seven groups according to decellularization protocols. After decellularization, cellular regions, matrix and strength and endurance of the scaffold were followed up. RESULTS: DNA content in all groups was measured under 50 ng/mg and there was no significant difference for the glycosaminoglycan content between group 3 (lyophilization+deoxycholic acid+de-oxyribonuclease method) and control group (P=0.46). None of the decellularized groups was different than the normal trachea in tensile stress values (P>0.05). Glucose consumption and lactic acid levels measured from supernatants of all decellularized groups were close to group with cells only (76 mg/dL and 53 mg/L). CONCLUSION: Using combination methods may reduce exposure to chemicals, prevent the excessive influence of the matrix, and shorten the decellularization time.

Modified midfacial degloving approach for sinonasal tumors.

A perfect surgical approach to nasal cavity and paranasal sinus tumors should provide a broad exposition preserving the important structures with no cosmetic defect. Midfacial degloving (MD) technique provides good exposure without incisions and scars in the face. Classic MD technique includes rhinoplasty incisions. However, combination of the facial plastic skills of the rhinoplasty techniques with an oncologic approach limits its popularity. We modified the classic technique, which is performed without classic rhinoplasty incisions. The surgical approaches to 55 patients with benign and malignant sinonasal neoplasms are reviewed, and the modification of MD technique performed without rhinoplasty incisions is described. The study includes 41 male and 13 female patients with both benign and malignant sinonasal neoplasms. The ages of the patients were between 9 and 78 years with a mean age of 41.15 years. Follow-up of the patients ranged from 2 to 96 months with a mean of 31.7 months. Most of the cases were angiofibroma and inverted papilloma. Modified MD approach was used for all patients, and in 6 cases, the technique was combined with subcranial approach. We successfully resected the tumors in all of the patients. The most frequently encountered complaint in the postoperative period was temporary nasal crusting and epistaxis. An important complication was the rupture of subpetrous part of the internal carotid artery in one patient and also a temporary facial palsy in another one. Palatal dysfunction, oroantral fistula, or vestibular stenosis, which are significant complications of MD, were not observed in any of our cases. In this modified technique, rhinoplasty incisions are not used; therefore, the duration of operation is shortened, the technique becomes easier, and the incisions of the rhinoplasty procedure, which could cause circular stenosis, are avoided.

Surgical treatment of laryngeal tumors with subglottic extension and tracheal tumors with composite nasal septal cartilage graft: technique and outcome.

OBJECTIVE: Composite nasal septal cartilage grafts (CNSCG) are effective grafting materials in laryngeal and tracheal reconstruction following tumor resection. METHODS: Between 1985 and 2005, we used CNSCG for the reconstruction of defects following resection of laryngeal tumors with subglottic extension (20 cases), subglottic mesenchymal tumors (2 cases), invasive thyroid carcinoma (4 cases), tracheal tumors (3 cases) and esophagus carcinoma with tracheal invasion (1 case) in total of 30 patients. RESULTS: The patients with subglottic tumors were decanulated within 5-7 days except one case. We achieved satisfactory voice and swallowing without any sign of recurrence. Overall complications consisted of subglottic stenosis in one case, and unilateral paralysis of recurrent laryngeal nerve in two cases. One patient with subglottic laryngeal carcinoma died due to neck and distant metastases 4 years after the operation. All patients are well with a mean follow-up period 9 years. Three patients with tracheal tumors underwent lateral resection and reconstructed with CNSCG. Satisfactory healing of the grafts was seen in all cases without local recurrence or complication with a mean follow-up period of 62 months. One of the patients had distant metastases 3 years after the operation. The patient with esophagus carcinoma and tracheal invasion was treated by total esophagectomy, gastric pull-up, tracheal resection and CNSCG reconstruction. He died at postoperative 5th day due to mediastinitis as a complication of gastric pull-up. CONCLUSION: Free composite cartilage graft is a reliable material in the reconstruction of defects after surgery of laryngeal tumors with subglottic extension, invasive thyroid and esophagus tumors and well-selected tracheal tumors.

Vibration characteristics of grafts for the tympanic membrane.

Perforation of the tympanic membrane occurs frequently as a result of infection, external trauma, and high-level impulsive sound pressure, such as that associated with an explosion. Many different surgical techniques can be used to repair the tympanic membrane and ossicles. Clinical operations such as tympanoplasty are undertaken to repair the damaged tympanic membrane and ossicles, thus improving hearing and reducing the chance of infection. The membrane is repaired or replaced with the use of graft materials, either from the patient's body or from artificial sources. The selection of graft material is very important because, as much as possible, it must exhibit the same dynamic behavior as the natural membrane. To compare various allograft materials, investigators developed a model of the ear on which different graft materials can be replaced. Three different membrane materials - irradiated allograft dura (Tutoplast Dura; IOP Inc., Costa Mesa, Calif), irradiated allograft fascia lata (Tutoplast Fascia Lata; IOP Inc.), and irradiated allograft fascia temporalis (Tutoplast Fascia Temporalis; IOP Inc.) - were used. Vibration responses of these membrane materials produced by defined sound signals with different frequencies were recorded by a small strain gauge; the spectra of sound for various corresponding input signals were recorded, and the results were compared with those of the sample graft material. Tutoplast Fascia Lata accomplished the best dynamic performance in vitro. Additional clinical and experimental data are needed, however, to determine which of these materials provides the best audiological and clinical performance.

Differences of the Voice Parameters Between the Population of Different Hearing Tresholds: Findings by Using the Multi-Dimensional Voice Program.

OBJECTIVES: To compare voice parameters in subjects with different hearing level. METHODS: The evaluation consisted of Multi-Dimensional Voice Program (MDVP) and electroglottography. Group 1 consisted of normal hearing subjects which is bilateral average hearing better than 25 decibels (dB) whereas group 2 consisted of patients who have bilateral average hearing between the 25 and 60 dB and group 3 consisted of patients who have bilateral average hearing between the 60 and 90 dB. The evaluations were performed on males and females separately. RESULTS: In female subjects, fundamental frequency (F0), absolute jitter, %jitter and soft phonation index (SPI) were significantly different between the group 1 and group 2. Also, we detected significant difference on maximum phonation time (MPT), fundamental frequency, absolute jitter and %jitter, and variable F0 (vF0) values between group 1 and group 3. Male subjects demonstrated significant difference between the group 1 and group 2 in MPT, absolute jitter, %jitter, vF0, and SPI parameters. Between the group 3 and group 1; differences in absolute jitter, %jitter, shimmer, %shimmer, vF0, and SPI were also significant. CONCLUSION: This study concluded that even mild to moderate hearing losses may affect voice patterns in adults and also females and males react differently to hearing loss in some parameters.

The Anatomical Relationship Between Recurrent Laryngeal Nerve and First Tracheal Ring in Males and Females.

OBJECTIVES: Despite the modern advances in thyroid surgery, recurrent laryngeal nerve (rln) paralysis is still a critical problem. In order to decrease the rate of this complication, rln anatomy has been studied intensively. In our study, we aimed to recognize the relationship of rln and landmarks of the first tracheal ring. METHODS: Eighty-six female and 18 male patients who were undergone total thyroidectomy were included in this study. Trachea vertical height (tvh), right recurrent laryngeal nerve height (rrh), left recurrent laryngeal nerve height (lrh), right recurrent laryngeal nerve to trachea anterior face median raphe distance (rrd), left recurrent laryngeal nerve to trachea anterior face median raphe distance (lrd), right recurrent laryngeal nerve respect to trachea ratio (rrtr), and left recurrent laryngeal nerve respect to trachea ratio (lrtr) parameters of all patients were measured and compared in males and females using independent t-test and measurements on both right and left sides were compared statistically without sex discrimination. RESULTS: There were no significant differences between groups in tvh, rrh, rrd, lrd, rrtr, and lrtr parameters. Lrh parameter was significantly higher in males than in females (P<0.04). Comparison of right and left sides revealed that lrh was significantly higher than rrh (P<0.001), lrd was significantly higher than rrd (P<0.001), and rrtr was significantly higher than lrtr (P<0.001). CONCLUSION: In this study, we have shown that in all cases the rln was located around the lower half of trachea vertical length and at this level left rln was located significantly deeper than the right side.