How I do it: implantation of Osia® 2 system under local anesthesia.

INTRODUCTION: Reviewing the literature, Osia 2 system implantation is predominantly performed under general anesthesia (GA). Although in the pediatric population GA is inevitable, in adult cases, especially with high anesthesiological risks, local anesthesia (LA) is an obvious solution. METHOD: The aim of this article is to provide a detailed demonstration of Osia 2 implantation under LA. In our case series of five adult implant recipients, the surgical procedure was carried out without encountering any difficulties during or after the operation. CONCLUSION: Based on our experiences, implantation of the Osia® 2 System under local anesthesia is an easy and safe method for patients.

Minimally invasive subperiosteal pocket technique for Osia 2 system- implantation without fixation.

The CochlearTM Osia® 2 is an active transcutaneous implant designed to treat patients with different types of hearing loss. Due to its size, implantation needs appropriate practice since the necessity of extended flap creation and bone work can be an issue in some cases. The goal of our study was to determine whether fixation of the OSI200 implant was necessary for the performance of patients with conductive or mild mixed hearing loss.The vibroacoustic performance of the Osia 2 system, with and without BI300 fixation, was evaluated through tests conducted on a head model. In addition, three patients underwent surgery using the modified minimally invasive subperiosteal pocket technique; the OSI200 implant was placed in a tight subperiosteal pocket without fixing it with the BI300 implant. To evaluate the audiological performance of the non-fixated Osia 2 system, we compared the preoperative unaided pure tone and suprathreshold testing with the Baha 5 sound processor and the non-fixated Osia 2 system aided thresholds.Initial results indicate that omitting fixation does not significantly impair the function of the Osia 2 system. The findings of the clinical assessment support the fact that the Osia 2 system performed better than the Baha 5 system on Softband, both in pure tone and suprathreshold tests.According to our results, we have found that utilizing the subperiosteal pocket method and implanting Osia 2 without BI300 fixation may be a viable option. This approach has shown promising results in terms of improving hearing ability with minimalization of surgery related complications.

Tilorone increases glucose uptake in vivo and in skeletal muscle cells by enhancing Akt2/AS160 signaling and glucose transporter levels.

Skeletal muscle plays a major role in whole-body glucose metabolism. Insulin resistance in skeletal muscle is characterized by decreased insulin-stimulated glucose uptake resulting from impaired intracellular trafficking and decreased glucose transporter 4 (GLUT4) expression. In this study, we illustrated that tilorone, a low-molecular-weight antiviral agent, improves glucose uptake in vitro and in vivo. Tilorone increased bone morphogenetic protein (BMP) signaling in C2C12 myoblasts, the transcription of multiple BMPs (BMP2, BMP4, BMP7, and BMP14), Smad4 expression, and the phosphorylation of BMP-mediated Smad1/5/8. The activation of Akt2/AS160 (TBC1D4) signaling, the critical regulator of GLUT4 translocation, was also increased, as well as the levels of GLUT4 and GLUT1, leading to enhanced uptake of the radioactively labeled glucose analog 18 F-fluoro-2-deoxyglucose (18 FDG). However, this excess glucose content did not result in increased ATP formation by mitochondrial respiration; both basal and ATP-linked respiration were diminished, thereby contributing to the induction of AMPK. In differentiated myotubes, AS160 phosphorylation and 18 FDG uptake also increased. Moreover, tilorone administration further increased insulin-stimulated phosphorylation of Akt2 and glucose uptake of myotubes indicating an insulin-sensitizing effect. Importantly, during in vivo experiments, the systemic administration of tilorone resulted in increased 18 FDG uptake of skeletal muscle, liver, and adipose tissue in C57BL/6 mice. Our results provide new perspectives for the treatment of type 2 diabetes, which has a limited number of treatments that regulate protein expression or translocation.

Syndecan-4 affects myogenesis via Rac1-mediated actin remodeling and exhibits copy-number amplification and increased expression in human rhabdomyosarcoma tumors.

Skeletal muscle demonstrates a high degree of regenerative capacity repeating the embryonic myogenic program under strict control. Rhabdomyosarcoma is the most common sarcoma in childhood and is characterized by impaired muscle differentiation. In this study, we observed that silencing the expression of syndecan-4, the ubiquitously expressed transmembrane heparan sulfate proteoglycan, significantly enhanced myoblast differentiation, and fusion. During muscle differentiation, the gradually decreasing expression of syndecan-4 allows the activation of Rac1, thereby mediating myoblast fusion. Single-molecule localized superresolution direct stochastic optical reconstruction microscopy (dSTORM) imaging revealed nanoscale changes in actin cytoskeletal architecture, and atomic force microscopy showed reduced elasticity of syndecan-4-knockdown cells during fusion. Syndecan-4 copy-number amplification was observed in 28% of human fusion-negative rhabdomyosarcoma tumors and was accompanied by increased syndecan-4 expression based on RNA sequencing data. Our study suggests that syndecan-4 can serve as a tumor driver gene in promoting rabdomyosarcoma tumor development. Our results contribute to the understanding of the role of syndecan-4 in skeletal muscle development, regeneration, and tumorigenesis.

Genetic Etiology of Nonsyndromic Hearing Loss in Hungarian Patients.

Hearing loss is the most prevalent sensory disorder worldwide. The majority of congenital nonsyndromic hearing loss (NSHL) cases are caused by hereditary factors. Previously, the majority of NSHL studies focused on the GJB2 gene; however, with the availability of next-generation sequencing (NGS) methods, the number of novel variants associated with NSHL has increased. The purpose of this study was to design effective genetic screening for a Hungarian population based on a pilot study with 139 NSHL patients. A stepwise, comprehensive genetic approach was developed, including bidirectional capillary sequencing, multiplex ligation-dependent probe amplification (MLPA), and an NGS panel of 108 hearing loss genes. With our results, a genetic diagnosis was possible for 92 patients. Sanger sequencing and MLPA identified the genetic background of 50% of these diagnosed cases, and the NGS panel identified another 16%. The vast majority (92%) of the diagnosed cases showed autosomal recessive inheritance and 76% were attributed to GJB2. The implementation of this stepwise analysis markedly increased our diagnostic yield and proved to be cost-effective as well.

Pediatric morphometric study to guide the optimized implantation of the Osia® 2 implant system.

PURPOSE: Continuous technological advances result in the availability of new bone conduction hearing implants, of which their suitability for pediatric patients is of major concern. The CochlearTMOsia® 2 is a new active osseointegrated steady-state implant system that uses digital piezoelectric stimulation to treat hearing loss. The implant in the United States was approved for patients aged 12 years and above, whereas the CE mark is independent of age, the only requirement is body weight of at least 7 kg. Therefore, further clinical studies are required to assess device characteristics in younger patients. The aim of our study was to perform a morphometric study among 5-12-year-old children, and to develop a surgical protocol for Osia 2 system implantation based on these findings. METHODS: We examined retrospectively cranial CT scans of 5-12-year-old patients from our clinical database. We measured the bone and soft-tissue thickness in the region of interest, and the position of the sigmoid sinus. 3D printed temporal bones were also used for planning. RESULTS: Soft-tissue thickness varied between 3.2 ± 0.5 mm and 3.6 ± 0.6 mm and bone thickness varied between 3.5 ± 1.1 mm and 4.7 ± 0.3 mm. The sigmoid sinus was located 1.3 ± 0.2 cm posterior to the ear canal, and the anterior distance was 4.8 ± 0.9 to 7.1 ± 1.1 mm. CONCLUSIONS: Our morphometric studies showed that patients aged 5-12 have different anatomical dimensions compared to adults, but that implantation of the Osia 2 system is feasible in these patients using an altered implant positioning recommended by our data. The Cochlear™ Osia® 2 is, therefore, an option for hearing rehabilitation in younger pediatrics.

A new method of preoperative assessment of correct electrode array alignment based on post-operative measurements in a cochlear implanted cohort.

PURPOSE: During cochlear implantation surgery, a range of complications may occur such as tip fold-over. We recently developed a method to estimate the insertion orientation of the electrode array. The aim of the study was to determine the optimal angle of orientation in a cohort of cochlear implanted patients. METHODS: On eighty-five CT scans (80 uncomplicated insertions and 5 cases with tip fold-over), location of the electrode array's Insertion Guide (IG), Orientation marker (OM) and two easily identifiable landmarks (the round window (RW) and the incus short process (ISP)) were manually marked. The angle enclosed by ISP-RW line and the Cochlear™ Slim Modiolar electrode array's OM line determined the electrode array insertion angle. RESULTS: The average insertion angle was 45.0-47.2° ± 10.4-12° SD and was validated with 98% confidence interval. Based on the measurements obtained, patients' sex and age had no impact on the size of this angle. Although the angles of the tip fold-over cases (44.9°, 46.9°, 34.2°, 54.3°, 55.9°) fell within this average range, the further it diverted from the average it increased the likelihood for tip fold-over. CONCLUSION: Electrode array insertion in the individually calculated angle relative to the visible incus short process provides a useful guide for the surgeon when aiming for the optimal angle, and potentially enhances good surgical outcomes. Our results show that factors other than the orientation angle may additionally contribute to failures in implantation when the Slim Modiolar electrode is used.

Functional results of endoscopic arytenoid abduction lateropexy for bilateral vocal fold palsy.

PURPOSE: Endoscopic arytenoid abduction lateropexy (EAAL) is a reliable surgical solution for the minimally invasive treatment of bilateral vocal fold palsy (BVFP), providing a stable airway by the lateralization of the arytenoid cartilages with a simple suture. The nondestructive manner of the intervention theoretically leads to higher regeneration potential, thus better voice quality. The study aimed to investigate the respiratory and phonatory outcomes of this treatment concept. METHODS: 61 BVFP patients with significant dyspnea associated with thyroid/parathyroid surgery were treated by unilateral EAAL. Jitter, Shimmer, Harmonics to Noise Ratio, Maximum Phonation Time, Fundamental frequency, Voice Handicap Index, Dysphonia Severity Index, Friedrich's Dysphonia Index, Global-Roughness-Breathiness scale, Quality of Life, and Peak Inspiratory Flow were evaluated 18 months after EAAL. RESULTS: All patients had a stable and adequate airway during the follow-up. Ten patients (16.4%) experienced complete bilateral motion recovery with objective acoustic parameters in the physiological ranges. Most functional results of the 13 patients (21.3%) with unilateral recovery also reached the normal values. Fifteen patients (24.6%) had unilateral adduction recovery only, with slightly impaired voice quality. Eleven patients (18.0%) had false vocal fold phonation with socially acceptable voice. In 12 patients (19.7%) no significant motion recovery was detected on the glottic level. CONCLUSION: EAAL does not interfere with the potential regeneration process and meets the most important phoniatric requirements while guaranteeing the reversibility of the procedure-therefore serving patients with transient palsy. Further, a socially acceptable voice quality and an adequate airway are ensured even in cases of permanent bilateral vocal fold paralysis.

Use of Self-Assembled Colloidal Prodrug Nanoparticles for Controlled Drug Delivery of Anticancer, Antifibrotic and Antibacterial Mitomycin.

Herein we present the synthesis of a polymeric prodrug nanomaterial capable of spontaneous, self-assembled nanoparticle formation and of the conjugation (encapsulation) of drugs with amino and/or carboxyl and/or hydroxyl groups via ester and/or amide linkage. Mitomycin C (MMC) a versatile drug with antibiotic, antibacterial and antineoplastic properties, was used to prove this concept. The in vitro drug release experiments showed a fast release for the pure MMC (k = 49.59 h-n); however, a significantly lower MMC dissolution rate (k = 2.25, 1.46, and 1.35 h-n) was obtained for the nanoparticles with increased cross-link density (3, 10, 21%). The successful modification and conjugation reactions were confirmed using FTIR and EDX measurements, while the mucoadhesive properties of the self-assembled particles synthesized in a simple one-pot reaction were proved by rheological measurement. The prepared biocompatible polymeric prodrugs are very promising and applicable as a drug delivery system (DDS) and useful in the area of cancer treatment.

A new method to determine the optimal orientation of Slim Modiolar cochlear implant electrode array insertion.

BACKGROUND AND PURPOSE: Our goal was to determine the optimal orientation of insertion of the Slim Modiolar electrode and develop an easy-to-use method to aid implantation surgery. In some instances, the electrode arrays cannot be inserted in their full length. This can lead to buckling, interscalar dislocation or tip fold-over. In our opinion, one of the possible reasons of tip fold-over is unfavourable orientation of the electrode array. Our goal was to determine the optimal orientation of the Slim Modiolar electrode array relative to clear surgical landmarks and present our method in one specified case. METHODS: For the measurement, we used the preoperative CT scan of one of our cochlear implant patients. These images were processed by an open source and free image visualization software: 3D Slicer. In the first step we marked the tip of the incus short process and then created the cochlear view. On this view we drew two straight lines: the first line represented the insertion guide of the cochlear implant and the second line was the orientation marker (winglet). We determined the angle enclosed by winglet and the line between the tip of the incus short process and the cross-section of previously created two lines. For the calculation we used a self-made python code. RESULTS: The result of our algorithm for the angle was 46.6055°. To validate this result, we segmented, from the CT scan, the auditory ossicles and the membranaceous labyrinth. From this segmentation we generated a 3D reconstruction. On the 3D view, we can see the position of the previous lines relative to the anatomical structures. After this we rotated the 3D model together with the lines so that the insertion guide forms a dot. In this view, the angle was measured with ImageJ and the result was 46.599°. CONCLUSION: We found that our method is easy, fast, and time-efficient. The surgery can be planned individually for each patient, based on their routine preoperative CT scan of the temporal bone, and the implantation procedure can be made safer. In the future we plan to use this method for all cochlear implantation surgeries, where the Slim Modiolar electrode is used.

Review of electrode placement with the Slim Modiolar Electrode: identification and management.

Background - Several cochlear implant recipients experience functionality loss due to electrode array mal-positioning. The application of delicate perimodiolar electrodes has many electrophysiological advantages, however, these profiles may be more susceptible to tip fold-over. Purpose - The prompt realization of such complication following electrode insertion would be auspicious, thus the electrode could be possibly repositioned during the same surgical procedure. Methods - The authors present three tip fold-over cases, experienced throughout their work with Slim Modiolar Electrode implants. Implantations were performed through the round window approach, by a skilled surgeon. Standard intraoperative measurements (electric integrity, neural response telemetry, and electrical stapedial reflex threshold tests) were successfully completed. The electrode position was controlled by conventional radiography on the first postoperative day. Results - Tip fold-over was not tactilely sensated by the surgeon. Our subjects revealed normal intraoperative telemetry measurements, only the postoperative imaging showed the tip fold-over. Due to the emerging adverse perception of constant beeping noise, the device was replaced by a CI512 implant after 6 months in one case. In the two remaining cases, the electrode array was reloaded into a back-up sheath, and reinserted into the scala tympani successfully through an extended round window approach. Discussion - Future additional studies using the spread of excitation or electric field imaging may improve test reliability. As all of these measurements are still carried out following electrode insertion, real-time identification, unfortunately, remains questionable. Conclusion - Tip fold-over could be reliably identified by conventional X-ray imaging. By contrast, intraoperative electrophysiology was not sufficiently sensitive to reveal it.

Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo - a clinico-pathological case reporT.

BACKGROUND AND PURPOSE: Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose - Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. METHODS: A 56-year-old male patient's interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. RESULTS: During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion - It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the "seed and soil" theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. CONCLUSION: Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.

Glottic configuration changes and outcomes of endoscopic arytenoid abduction lateropexy.

INTRODUCTION: Endoscopic arytenoid abduction lateropexy (EAAL) is an effective glottis enlarging procedure for the treatment of bilateral vocal cord palsy (BVCP). The postoperative glottic configuration changes can be evaluated by modern, high-resolution, 3D image reconstructions. Functional results are described by spirometry as well as objective and subjective phoniatric tests. METHODS: Unilateral EAAL was performed in ten malignant thyroid gland tumor patients (eight women, two men), who had BVCP after thyroid surgery. Slicer 3D® software was used for morphometric analysis. Pre- and postoperative peak inspiratory flow (PIF) and standard phoniatric parameters were compared. RESULTS: The glottic gap improved significantly (+ 60%). Significant improvement of PIF was found in all cases. Phoniatric tests revealed better quality of voice and patient satisfaction. Their voices changed from a severely impaired to a socially acceptable, almost normal, quality. CONCLUSION: The results support our clinical observations that the ideal position of the lateralization sutures is the one which provides a physiological abduction position of the arytenoid cartilage. Considering these good results, the surgical indications for minimally invasive endoscopic arytenoid lateropexy may be extended.

[Phoniatric outcomes of endoscopic arytenoid abduction lateropexy in patients with transient bilateral vocal cord paralysis]. / Endoszkópos arytaenoid abdukciós lateropexia foniátriai eredményei átmeneti kétoldali gégebénulás esetén.

INTRODUCTION: Dyspnea caused by bilateral vocal cord paralysis often requires surgical intervention to prevent acute asphyxiation. The regeneration of the laryngeal nerves may last weeks or months and it is difficult to predict the outcome. In the past decades, several open and endoscopic surgical techniques have been introduced for treatment to avoid tracheostomy, however, these procedures with resection of the glottis resulted in irreversible changes in the laryngeal structure, thus the voice quality decreased over a long-term period. AIM: Endoscopic arytenoid abduction lateropexy is an accepted reversible, minimally invasive technique that provides an immediate patent airway by the lateralisation of the arytenoid cartilage with a suture. The aim of our study was to analyze the phonatory and respiratory outcomes of this treatment concept. METHOD: Two patients suffering from bilateral vocal cord palsy were treated with endoscopic arytenoid abduction lateropexy. After recovery of the vocal cord movements, the sutures were removed. Spirometric and phoniatric results of the two patients were analysed after suture removal. RESULTS: Good spirometric parameters and normal voice quality were detected in both cases. CONCLUSIONS: These results prove the high reversibility of the minimally invasive endoscopic arytenoid abduction lateropexy. Lateralization suture can be removed in the case of vocal cord movement recovery, and phonation may be physiological. Orv Hetil. 2018; 159(29): 1188-1192.

[The role of laryngeal electromyography in the diagnosis of vocal cord movement disorders]. / A laryngealis electromyographia szerepe a hangszalag-mozgászavarok diagnosztikájában és az alkalmazott kezelés kiválasztásában.

The development of the therapeutic possibilities of vocal cord immobility necessitated the parallel renewal of diagnostic methods. In the last years, laryngeal electromyography, which was first introduced more than 70 years ago, has been re-discovered. After reviewing the international literature and their own experience, the authors present the indications, technical requirements, method and, particularly, the evaluation of the results of this procedure. Laryngeal electromyography makes the differentiation between mechanical fixation and immobility with neurological origin of the vocal folds possible. In case of laryngeal paralysis/paresis it also evaluates objectively the severity of neural injury, the prognosis of the disease and the necessity of any glottis-widening procedure. The widespread application of dynamic rehabilitation interventions is not conceivable without the routine application of laryngeal electromyography, so this sensitive diagnostic tool has to be introduced in all laryngological centers. Orv Hetil. 2018; 159(8): 303-311.

[Possibilities for residual hearing preservation with Nucleus CI532 Slim Modiolar electrode array. Case report]. / A maradványhallás megorzésének lehetoségei cochlearis implantáció során Nucleus CI532 Slim Modiolar elektródasorral.

During the rehabilitation of hearing-impaired patients, the preservation of residual acoustic hearing following cochlear implantation by minimizing the implantation trauma allows for improved hearing performance. To achieve this, minimally invasive, soft surgery methods and thinner, atraumatic electrodes were required. In our present study, we reported a case where Cochlear® Nucleus CI532 Slim Modiolar electrode was implanted in a patient with residual hearing. Our aim was to study the possible preservation of postoperative acoustic residual hearing by audiological monitoring. Since childhood, due to her congenital hearing loss, she has been wearing a conventional, airborne hearing correction device on both ears. Six months before cochlear implantation, we measured the progression on both sides of the hearing loss, so we decided to perform cochlear implantation. The patient had residual hearing on both ears prior to surgery thus the Cochlear® Nucleus CI532 Slim Modiolar Implant was used. The minimally invasive surgery was performed on the patient's right ear through the round window approach. Compared to the preoperative hearing threshold (average 85 dBHL) in the 4th postoperative week, an initial hearing threshold progression of 20-25 dBHL was observed between 0.25 and 1.0 kHz, while of 5-10 dBHL between 2.0-4.0 kHz. Hearing threshold measured in the 6th month showed a slight progression in the range above 1 kHz, but improved by the 12th month, to the results achieved at the 4th week. The effects of cochlear implantation on residual hearing have been studied in numerous studies, in which several key surgical and technical factors have been identified. Nucleus CI532 is a Slim Modiolar electrode profile that is close to the modiolus, so it is expected to have a lower endocochlear hydrodynamic load since it lies in the covering of the osseus spiral lamina, thus less influencing the dynamics of the basilar membrane. However, the perimodiolar location of the electrode array allows the adjacent nerve elements of the spiral ganglion to be stimulated with a lower electrical intensity and a reduced surface that may be neuroprotective. Preservation of acoustic residual hearing following cochlear implantation improves the patient's speech perception and the sound localization skills, particularly in difficult circumstances. Long-term residual hearing preservation may also be of great importance in the subsequent feasibility for regenerative procedures and drug treatments. Orv Hetil. 2018; 159(41): 1680-1688.

[Effects of nasal provocation with a single-dose allergen on the explicit and implicit memory of physically active and inactive patients with ragweed allergy]. / Az egyszeri allergéndózis hatása az explicit-implicit emlékezetre parlagfu-allergiás sportoló és nem sportoló betegeken.

BACKGROUND AND PURPOSE: Allergy is an endemic disease and has a considerable impact on the quality of life. This study aimed to measure the effect of active allergic rhinitis on memory functions of physically active and inactive patients with ragweed allergy. METHODS: Memory functions were assessed before and after allergen exposure. Participants in both groups were provoked nasally with 30 IR/mL ragweed allergen in each nostril. Explicit memory was measured with story-recalling and implicit memory was investigated with reaction time task. RESULTS: In neuropsychological assessments athletes performed significantly better, compared with the control group after allergen provocation in short-term and long-term memory functions. There was no difference between the groups in the implicit tasks. Athletes have achieved better results after provocation, comparing to the baseline test and the tests that measured short-term and long-term memory functions. CONCLUSION: Short-term disturbing factors, e.g. swollen nasal mucosa, sneezing, and watery eyes after provocation did have not caused deterioration in cognitive functions. A single-shot allergen in high doses have caused an increase of mental concentration, which was more pronounced in athletes.

Esthetically Favorable Surgical Alternative for the Removal of Sinonasal Malignant Tumors-The Modified Facial Degloving Technique.

PURPOSE: The widely used external approach (Weber-Fergusson incision) for the removal of maxillary ethmoid tumors leaves stigmatizing scars and deformities on the patient's face. As an alternative technique, the scarless facial degloving approach was first described in the 1970s; since then, several modifications have been developed. PATIENTS AND METHODS: The authors have been using a modified facial degloving technique for 7 years to remove maxillary ethmoid tumors. This article is a retrospective methodologic review. The inclusion criteria for this retrospective study were patients who underwent the modified facial degloving technique for management of malignant maxillary ethmoid tumors. The exclusion criteria were patients who did not undergo a surgical procedure (who received primary chemoradiation therapy) and patients who underwent an endoscopic surgical procedure for an early-stage localized tumor. The authors describe their method, which provides for a wide surgical approach using an osteoplastic flap for the entire nasal and paranasal region, with good cosmetic results. They present the adaptability of their method for 3 malignant maxillary ethmoid tumors in different locations. RESULTS: From 2012 through 2016, 23 consecutive patients underwent surgery with the modified facial degloving approach at the Department of Otorhinolaryngology, Head and Neck Surgery at the University of Szeged (Szeged, Hungary). The authors evaluated their results with acoustic rhinometry and photographic documentation of postoperative facial expressions. Neither narrowing of the nasal cavity on the operated side (loss of nasal breathing function) nor facial movement dysfunction was visible in these patients. CONCLUSION: Although several modifications of the original facial degloving approach have been published, in the present technique, the novel osteoplastic flap and the intact soft tissue of the nasal and midfacial region result in shorter hospitalization time and fewer complications. No functional or esthetic distortion was visible. No severe complications were observed; the patients' only complaint was the dryness of the nasal mucosa and temporary crusting of the nose. The present modified facial degloving technique offers proper and safe surgical resection for tumors of the maxillary ethmoid region. It can be routinely combined with endoscopic techniques and, if necessary, can be converted to an open approach.

Functional outcomes of endoscopic arytenoid abduction lateropexy for unilateral vocal cord paralysis with dyspnea.

In unilateral vocal cord paralysis (UVCP), hoarseness is usually the leading symptom; however, the diminished airway might lead to breathing problems as well, especially with exertion. The application of the classic resection glottis enlarging or medialization procedures might shift the breathing and/or the voice to a worse condition. The non-destructive endoscopic arytenoid abduction lateropexy (EAAL) might be a solution for this problem. The aim of our study was to analyze the phonatory and respiratory outcomes of this treatment concept. The first year phoniatric [Jitter, Shimmer, harmonics-to-noise ratio (HNR), maximum phonation time (MPT), fundamental frequency (F 0), Voice Handicap Index (VHI), Dysphonia Severity Index (DSI), Global-Roughness-Breathiness scale (GRB)], peak inspiratory flow (PIF), and quality of life (QoL) were evaluated in ten UVCP patients treated by EAAL for dyspnea generally presented on exertion. PIF, Jitter, QoL, GRB, and VHI significantly improved. DSI, HNR, and MPT got non-significantly better. F 0 slightly increased in all patients, a mild deterioration of shimmer was observed. These results prove that improving respiratory function is not necessarily associated with a deterioration in voice quality. The EAAL provides a significant improvement in breathing and the vibratory parameters of the postoperative, more tensed and straightened vocal cords proved to be more advantageous than the original (para) median 'loose' position. The over-adduction of the contralateral side more or less compensates for the disadvantageous, more lateral position of the operated side. EAAL might be an alternative treatment for unilateral vocal cord paralysis associated with breathing problems.