Does the ChOLE classification relate to the duration of surgery?

INTRODUCTION: Cholesteatoma, a challenging entity in otologic surgery, necessitates a standardized classification system for effective communication among healthcare providers and consistent reporting of surgical outcomes. The ChOLE Classification System, introduced by Linder et al., stages cholesteatoma based on extension (Ch), ossicular chain status (O), life-threatening complications (L), and Eustachian tube function and mastoid pneumatization (E). METHODS: We classified 199 patients who underwent cholesteatoma surgery between 2019 and 2023 in our University Hospital to assess the distribution of the ChOLE stages and to examine the relationship between the ChOLE stages and the duration of surgery. RESULTS: This study revealed significant correlations between the ChOLE stage and respective subgroups of the classification and duration of surgery and thus complexity of procedure. CONCLUSION: Despite limitations, the ChOLE classification proves valuable in predicting surgical complexity and optimizing patient care. Further research is warranted to validate these findings and enhance cholesteatoma management strategies.

The extent of androgen receptor and HER2 expression allows for targeted therapy in most cases of salivary duct carcinoma: analysis of clinical and histopathological data in a tertiary care center.

PURPOSE: The incidence of salivary duct carcinoma (SDC) seems to be underestimated due to inaccurate classification. Further, the frequency of SDC patients with targeted therapy options according to current guidelines is unclear. Therefore, this study aimed at (a) describing the proportion of SDC among salivary gland carcinoma (SGC) before and after reclassification of cases initially classified as adenocarcinoma, not otherwise specified (ANOS); and (b) quantifying the frequency of SDC patients with targeted therapy options. METHODS: All patients with SDC or ANOS treated in a tertiary care center between 1996 and 2023 were identified. Histopathological diagnosis was verified for patients primarily diagnosed with SDC and reviewed for patients initially diagnosed with ANOS. Clinical data for SDC patients were retrieved from clinical charts. Immunohistochemical (IHC) androgen receptor (AR) and HER2 staining was performed. RESULTS: Among 46 SDC, 34 were primarily diagnosed as SDC and 12 had initially been classified as ANOS. The proportion of SDC among SGC was 12.1% and was rising when comparing the time periods 2000-2015 (7.1-11.5%) versus 2016-2023 (15.4-18.1%). Nuclear AR staining in > 70% of tumor cells was found in 56.8% and HER2 positivity (IHC 3 +) in 36.4% of cases. 70.5% of patients showed AR staining in > 70% of tumor cells and/or HER2 positivity and therefore at least one molecular target. 5-year overall and disease-free survival (DFS) were 62.8% and 41.0%. Multivariate Cox regression revealed positive resection margins (HR = 4.0, p = 0.03) as independent negative predictor for DFS. CONCLUSIONS: The results suggest a rising SDC incidence and show that the extent of the AR and HER2 expression allows for targeted therapy in most SDC cases.

[Vestibular Schwannoma: Factors in Therapy Decision-Making]. / Vestibularisschwannom: Faktoren bei der Therapieentscheidung.

The treatment of vestibular schwannomas (VS) has always posed a challenge for physicians. Three essential treatment principles are available: wait-and-scan, surgery, and stereotactic radiotherapy. In addition to the type of treatment, decisions must be made regarding the optimal timing of therapy, the combination of different treatment modalities, the potential surgical approach, and the type and intensity of radiation. Factors influencing the therapy decision include tumor location and size or stage, patient age, comorbidities, symptoms, postoperative hearing rehabilitation options, patient preferences, and, not least, the experience of the surgeons and the personnel and technical capabilities of the clinical site. This article begins with a brief overview of vestibular schwannomas, then outlines the fundamental interdisciplinary treatment options, and finally discusses the ENT (ear, nose, and throat)-relevant factors in the therapy decision.

Experimental ex-vivo performance study comparing a novel, pulsed thulium solid-state laser, chopped thulium fibre laser, low and high-power holmium:YAG laser for endoscopic enucleation of the prostate.

PURPOSE: The aim of this study was to compare the enucleation performances of four different types of laser devices in an ex-vivo experiment: a novel, pulsed Tm:YAG solid-state laser evaluation model (p-Tm:YAG), chopped thulium fibre laser (TFL), low-power Ho:YAG laser (LP-Ho:YAG), and a high-power Ho:YAG laser (HP-Ho:YAG). METHODS: Our primary aim was to endoscopically separate the fascial layers of a porcine belly using laser fibres within a time period of 60 s. The size of a "tissue pocket" was assessed numerically. The enucleation characteristics reflecting the surgeon's experience were evaluated via the NASA Task Load Index (TLX) questionnaire and a questionnaire based on Likert scale. RESULTS: HP-Ho:YAG achieved with the available laser settings the largest overall "tissue pocket" (31.5 cm2) followed by p-Tm:YAG (15 cm2), TFL (12 cm2), and LP-Ho:YAG (6 cm2). The coagulation performances of p-Tm:YAG and TFL were rated the best. In the performance evaluation by the Likert questionnaire, HP-Ho:YAG (average score of 4.06) was rated highest, followed by p-Tm:YAG (3.94), TFL (3.38), and LP-Ho:YAG (3.25). The evaluation of the NASA-TLX performance questionnaire revealed average scores for HP-Ho:YAG, LP-Ho:YAG, TFL and p-Tm:YAG of 4.38, 4.09, 3.92 and 3.90, respectively. CONCLUSION: We are the first to compare different laser devices and settings in an ex-vivo study. We found that the surgeons were most satisfied with the HP-Ho:YAG laser device, followed by the p-Tm:YAG. These findings could be highly relevant for future research and for the practical utilisation of laser systems in endourology.

Antibodies and IL-3 support helminth-induced basophil expansion.

Basophils are powerful mediators of Th2 immunity and are present in increased numbers during allergic inflammation and helminth infection. Despite their ability to potentiate Th2 immunity the mechanisms regulating basophil development remain largely unknown. We have found a unique role for isotype-switched antibodies in promoting helminth-induced basophil production following infection of mice with Heligmosomoides polygyrus bakeri or Nippostrongylus brasiliensis. H. polygyrus bakeri-induced basophil expansion was found to occur within the bone marrow, and to a lesser extent the spleen, and was IL-3 dependent. IL-3 was largely produced by CD4(+)CD49b(+)NK1.1(-) effector T cells at these sites, and required the IL-4Rα chain. However, antibody-deficient mice exhibited defective basophil mobilization despite intact T-cell IL-3 production, and supplementation of mice with immune serum could promote basophilia independently of required IL-4Rα signaling. Helminth-induced eosinophilia was not affected by the deficiency in isotype-switched antibodies, suggesting a direct effect on basophils rather than through priming of Th2 responses. Although normal type 2 immunity occurred in the basopenic mice following primary infection with H. polygyrus bakeri, parasite rejection following challenge infection was impaired. These data reveal a role for isotype-switched antibodies in promoting basophil expansion and effector function following helminth infection.

The TORP-PORP: A Tympanoplasty Technique for Isolated Defects of the Stapes Suprastructure.

OBJECTIVE: Investigating the outcomes of a surgical approach to treat isolated defects of the stapes suprastructure, using a modified total ossicular replacement prosthesis (TORP) prosthesis as a PORP between the footplate and the incus, effectively creating a TORP-PORP configuration. PATIENTS: Eleven patients (mean age, 37.2 years; 36% male and 64% female) between the years 2007 and 2022. INTERVENTIONS: Therapeutic (ossiculoplasty). MAIN OUTCOME MEASURES: Hearing gain (in dB) in air conduction thresholds at 0.5, 1, 2, 3, and 4 kHz, stability of bone conduction, revision rate. RESULTS: Significant improvement in air conduction between the preoperative and the postoperative cohorts (p = 0.002) with a mean postoperative hearing level of 30.00 ± 5.25 dB. The bone conduction remained stable. We encountered no perioperative complications, and there were no revisions surgery. CONCLUSIONS: The described ossiculoplasty procedure is a safe and effective approach to treat isolated defects of the stapes suprastructure.

Bi-institutional analysis of microbiological spectrum and therapeutic management of parotid abscesses.

BACKGROUND: A parotid abscess (PA) is a complication of an acute bacterial parotitis with a potentially life-threatening course. To date, data on the diagnosis and therapy of PA is sparse and mostly consists of case reports or case series. Therefore, this study aimed at comprehensively analyzing the microbiological spectrum and the therapeutic management in a bi-institutional setting. METHODS: A retrospective clinical chart review was performed to identify all patients surgically treated for PA at two tertiary care centers in Germany. Data on demographics, clinical management and microbiological data including species identification, pathogenicity, type of antibiotic therapy, adjustment of antibiotics, antibiotic sensitivity testing, and smear test results were extracted. Intervention-related variables and etiology were analyzed for their statistical association with outcome variables. RESULTS: Overall, 85 patients were included. Most patients (92.9%) underwent surgical incision. Around half of the patients (45.9%) were treated under local anesthesia. No facial nerve palsy was observed. The most frequently detected pathogens were Streptococci (n = 23), followed by Staphylococcus aureus (n = 6) including one case of methicillin-resistant Staphylococcus aureus. Most patients (68.2%) received an aminopenicillin ± beta-lactamase inhibitor as empiric antibiotic therapy. In 6 cases the antibiotic therapy was modified after receiving the antibiogram. Four patients (5.2%) presented with recurrent PA. Etiology was idiopathic (42.4%), followed by tumorous (12.9%), obstructive, and immunosuppressive (each 11.8%). Patients with a dental focus (p = 0.007) had a longer duration of hospitalization. CONCLUSION: The results show that the surgical therapy of PA under local anesthesia is safe. A dental examination should routinely be performed to rule out a dental focus. Obtaining a microbiological specimen in order to modify antibiotic therapy if necessary and a histopathological specimen to rule out a tumorous etiology is obligate.

Co-expression patterns of cancer associated fibroblast markers reveal distinct subgroups related to patient survival in oropharyngeal squamous cell carcinoma.

Background: The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is rapidly increasing in high income countries due to its association with persistent high-risk human papilloma virus (HPV) infection. Recent scientific advances have highlighted the importance of the tumor microenvironment in OPSCC. In this study, including 216 OPSCC patients, we analyze the composition of four established markers of cancer associated fibroblasts (CAFs) in the context of intratumoral CD8 T-cell infiltration. Methods: Immunohistochemical staining for fibroblast activation protein (FAP), platelet-derived growth factor receptor beta (PDGFRb), periostin, alpha smooth muscle actin (α-SMA) and CD8 were analyzed digitally and their association with survival, tumor- and patient characteristics was assessed. Results: Co-expression of CAF markers was frequent but not associated with HPV status. FAPhigh and PDGFRbhigh expression were associated with increased CD8 T-cell infiltration. Low expression of PDGFRb improved patient survival in female patients but not in male patients. We identified PDGFRblow periostinlow α-SMAlow status as an independent predictor of improved survival (hazard ratio 0.377, p = 0.006). Conclusion: These findings elucidate the co-expression of four established CAF markers in OPSCC and underscore their association with T-cell infiltration and patient survival. Future analyses of CAF subgroups in OPSCC may enable the development of individualized therapies.

Zymosan suppresses leukotriene C4 synthase activity in differentiating monocytes: antagonism by aspirin and protein kinase inhibitors.

Cysteinyl leukotrienes (cysLTs) are potent proinflammatory mediators with particular relevance for asthma. However, control of cysLT biosynthesis in the time period after onset of acute inflammation has not been extensively studied. As a model for later phases of inflammation, we investigated regulation of leukotriene (LT) C(4) synthase (LTC(4)S) in differentiating monocytes, exposed for several days to fungal zymosan. Incubations with LTA(4) revealed 20-fold increased LTC(4)S activity during differentiation of monocytic Mono Mac 6 (MM6) cells, which was reduced by 80% in the presence of zymosan (25 µg/ml, 96 h). Zymosan (48 h) similarly attenuated LTC(4)S activity of primary human monocyte-derived macrophages and dendritic cells. Several findings indicate phosphoregulation of LTC(4)S: increased activity during MM6 cell differentiation correlated with reduced phosphorylation of 70-kDa ribosomal protein S6 kinase (p70S6K), which could phosphorylate purified LTC(4)S; the p70S6K inhibitor rapamycin (20 nM) doubled LTC(4)S activity of undifferentiated MM6 cells, and protein kinase A and C inhibitors (H-89, CGP-53353, and staurosporine) reversed the zymosan-induced suppression of LTC(4)S activity. Finally, zymosan (48 h) up-regulated PGE(2) biosynthesis, and aspirin (10 µM) or prostaglandin E(2) (PGE(2)) receptor antagonists counteracted the zymosan effect. Our results suggest a late PGE(2)-mediated phosphoregulation of LTC(4)S during microbial exposure, which may contribute to resolution of inflammation, with implications for aspirin hypersensitivity.

Safety and Efficacy of Laser Enucleation of the Prostate in Elderly Patients - A Narrative Review.

Benign prostatic hyperplasia (BPH) is a common health condition in aging men resulting in lower urinary tract symptoms (LUTS) and low quality of life (QoL). We aimed to review studies on laser enucleation of the prostate (LEP) due to LUTS in elderly patients (>65 years) comparing different age groups, particularly considering functional outcomes, safety, and perioperative complications. A comprehensive search was conducted using the PubMed-MEDLINE, Web of Science, Wiley Online Library and Cochrane Library databases over the last 10 years until 7 October 2021 with the following search terms solely or in combination: "laser enucleation", "prostate", "laser prostatectomy", "aging", "elderly patients", "older patients" and "age". We identified 12 articles for inclusion in our analysis. Five studies focussed mainly on holmium laser enucleation of the prostate (HoLEP), one compared HoLEP to other laser prostatectomy procedures, two studies examined thulium laser enucleation of the prostate (ThuLEP), and two studies focused on GreenLight laser, one study focussed on potassium-titanyl-phosphate (KTP) laser, and another study compared laser prostatectomy to transurethral resection of the prostate (TURP). These studies showed that LEP improved IPSS, Qmax and QoL compared to baseline regardless of age; no significant difference was reported among age groups. Although ASA scores and anticoagulation/antiplatelet therapy rates are higher in elderly patients, studies revealed no significant difference in perioperative complication rates between age groups. Laser enucleation of the prostate is an effective and safe procedure in elderly patients, resulting in good functional outcomes, low morbidity, and few perioperative complications.

Exosomes from human macrophages and dendritic cells contain enzymes for leukotriene biosynthesis and promote granulocyte migration.

BACKGROUND: Leukotrienes (LTs) are potent proinflammatory lipid mediators with key roles in the pathogenesis of asthma and inflammation. Recently, nanovesicles (exosomes), released from macrophages and dendritic cells (DCs), have become increasingly appreciated as messengers in immunity. OBJECTIVE: We investigated whether exosomes from human macrophages, DCs, and plasma contain enzymes for LT biosynthesis and studied potential roles for exosomes in transcellular LT metabolism and granulocyte chemotaxis. METHODS: The presence of LT pathway enzymes and LT biosynthesis in exosomes and cells was analyzed by Western blot, immunoelectron microscopy, and enzyme activity assays. Surface marker expression was evaluated by flow cytometry, and granulocyte migration was assessed in a multiwell chemotaxis system. RESULTS: Exosomes from macrophages and DCs contain functional enzymes for LT biosynthesis. After incubation of intact cells with the LT biosynthesis intermediate LTA(4), LTB(4) was the major product of macrophages, whereas DCs primarily formed LTC(4). However, in exosomes from both cell types, LTC(4) was the predominant LTA(4) metabolite. Exosomal LTC(4) formation (per milligram protein) exceeded that of cells. In macrophages and DCs, TGF-ß1 upregulated LTA(4) hydrolase along with increased LTB(4) formation also in the exosomes. Moreover, TGF-ß1 modified the expression of surface marker proteins on cells and exosomes and reduced the exosome yield from macrophages. On Ca(2+)-ionophore and arachidonic acid stimulation, exosomes produced chemotactic eicosanoids and induced granulocyte migration. Interestingly, active LTA(4) hydrolase and LTC(4) synthase were present also in exosomes from human plasma. CONCLUSION: Our findings indicate that exosomes can contribute to inflammation by participation in LT biosynthesis and granulocyte recruitment.

mTOR-dependent translation amplifies microglia priming in aging mice.

Microglia maintain homeostasis in the brain. However, with age, they become primed and respond more strongly to inflammatory stimuli. We show here that microglia from aged mice had upregulated mTOR complex 1 signaling controlling translation, as well as protein levels of inflammatory mediators. Genetic ablation of mTOR signaling showed a dual yet contrasting effect on microglia priming: it caused an NF-κB-dependent upregulation of priming genes at the mRNA level; however, mice displayed reduced cytokine protein levels, diminished microglia activation, and milder sickness behavior. The effect on translation was dependent on reduced phosphorylation of 4EBP1, resulting in decreased binding of eIF4E to eIF4G. Similar changes were present in aged human microglia and in damage-associated microglia, indicating that upregulation of mTOR-dependent translation is an essential aspect of microglia priming in aging and neurodegeneration.

Coactosin-like protein functions as a stabilizing chaperone for 5-lipoxygenase: role of tryptophan 102.

The activity of 5-LO (5-lipoxygenase), which catalyses two initial steps in the biosynthesis of pro-inflammatory LTs (leukotrienes), is strictly regulated. One recently discovered factor, CLP (coactosin-like protein), binds 5-LO and promotes LT formation. In the present paper we report that CLP also stabilizes 5-LO and prevents non-turnover inactivation of the enzyme in vitro. Mutagenesis of tryptophan residues in the 5-LO beta-sandwich showed that 5-LO-Trp102 is essential for binding to CLP, and for CLP to support 5-LO activity. In addition, the stabilizing effect also depended on binding between CLP and 5-LO. After mutations which prevent interaction (5-LO-W102A or CLP-K131A), the protective effect of CLP was absent. A calculated 5-LO-CLP docking model indicates that CLP may bind to additional residues in both domains of 5-LO, thus possibly stabilizing the 5-LO structure. To obtain further support for binding between CLP and 5-LO in a living cell, subcellular localization of CLP and 5-LO in the monocytic cell line Mono Mac 6 was determined. In these cells, 5-LO associates with a nuclear fraction only when differentiated cells are primed with phorbol ester and stimulated with ionophore. The same pattern of redistribution was found for CLP, indicating that the two proteins associate with the nucleus in a co-ordinated fashion. The results of the present study support a role for CLP as a chaperoning scaffold factor, influencing both the stability and the activity of 5-LO.

Influence of the internal disulfide bridge on the folding pathway of the CL antibody domain.

Disulfide bridges are one of the most important factors stabilizing the native structure of a protein. Whereas the basis for their stabilizing effect is well understood, their role in a protein folding reaction still seems to require further attention. We used the constant domain of the antibody light chain (C(L)), a representative of the ubiquitous immunoglobulin (Ig)-superfamily, to delineate the kinetic role of its single buried disulfide bridge. Independent of its redox state, the monomeric C(L) domain adopts a typical Ig-fold under native conditions and does not retain significant structural elements when unfolded. Interestingly, its folding pathway is strongly influenced by the disulfide bridge. The more stable oxidized protein folds via a highly structured on-pathway intermediate, whereas the destabilized reduced protein populates a misfolded off-pathway species on its way to the native state. In both cases, the formation of the intermediate species is shown to be independent of the isomerization state of the Tyr(141)-Pro(142) bond. Our results demonstrate that the internal disulfide bridge in an antibody domain restricts the folding pathway by bringing residues of the folding nucleus into proximity thus facilitating the way to the native state.