Effect of modern surgical treatment on the inflammatory/anti-inflammatory balance in patients with obstructive sleep apnoea.

OBJECTIVE: To investigate the inflammatory/anti-inflammatory cytokine balance - T helper 1/T helper 2 ratios - in obstructive sleep apnoea patients, before and after treatment. METHODS: Twenty-eight patients received continuous positive airway pressure treatment and 29 patients who could not tolerate continuous positive airway pressure were scheduled for surgery. Serum levels of interleukins 2, 4 and 10, tumour necrosis factor-alpha, and interferon gamma were analysed by enzyme-linked immunosorbent assays before and three months after treatment. RESULTS: The success rate of surgical treatment was 65.5 per cent. Mean compliance for the continuous positive airway pressure group was 40.9 per cent. The apnoea/hypopnoea index significantly decreased in both groups after treatment (p < 0.001). The interferon gamma/interleukin-4 ratio decreased following surgical treatment (p = 0.014), and the interleukin-2/interleukin-4 ratio decreased after treatment in 57 patients in the overall cohort (p = 0.032). CONCLUSION: After treatment for obstructive sleep apnoea, some ratios reflecting T helper 1/T helper 2 cytokine balance favoured the T helper 2 direction, suggesting a shift to an anti-inflammatory state. Successful surgery and better continuous positive airway pressure compliance can help ameliorate inflammation in obstructive sleep apnoea patients, which may reduce associated morbidities.

Impact of unilateral carbon dioxide laser posterior transverse cordotomy on vocal and aerodynamic parameters in bilateral vocal fold paralysis.

OBJECTIVES: Carbon dioxide laser posterior transverse cordotomy is a common option for bilateral vocal fold paralysis. This study prospectively evaluated aerodynamic and acoustic effects of unilateral carbon dioxide laser posterior transverse cordotomy in bilateral vocal fold paralysis patients. METHODS: The study comprised 11 bilateral vocal fold paralysis patients (9 females, 2 males), with a mean age of 46.6 ± 14.1 years. All patients were treated by laser posterior transverse cordotomy. Pre-operative and two-month post-operative assessments were conducted, including: dyspnoea scales, maximum phonation time measurement, spirometry and bicycle ergometry. RESULTS: All subjective and objective aerodynamic parameters showed statistically significant improvements between the pre- and post-operative period. Objective spirometric and ergometric parameters showed a significant increase post-operatively. The changes in objective voice parameters (fundamental frequency (f0), jitter, shimmer, soft phonation index and noise-to-harmonic ratio) were statistically non-significant; however, there was a significant improvement in subjective voice parameters post-operatively, as assessed by the voice handicap index and grade-roughness-breathiness-asthenia-strain scale (p = 0.026 and p = 0.018 respectively). CONCLUSION: Unilateral carbon dioxide laser posterior transverse cordotomy is an effective procedure that results in improved dyspnoea and aerodynamic performance with some worsening of voice parameters.

Use of the Berlin Questionnaire to screen at-risk patients for obstructive sleep apnea.

OBJECTIVE: To investigate the value of the Berlin Questionnaire (BQ) for screening at-risk patients for obstructive sleep apnea (OSA). MATERIALS AND METHODS: This study included 217 subjects who were referred to a Department of Otolaryngology, Head and Neck Surgery for evaluation of suspected OSA. The subjects were classified as being at high or low risk of OSA according to their BQ score. The apnea hypopnea index (AHI), body mass index (BMI), Epworth sleepiness score, and BQ results were compared in the two risk groups, and the correlation of BQ with AHI was analyzed. The predictive accuracy of risk grouping was assessed for AHI > 5 and AHI > 15. RESULTS: The BQ identified 82.03% of the subjects as being at high risk of sleep apnea and 17.9% as being at low risk. Using a cut-off point of AHI > 5, the sensitivity was 83.4% and the specificity was 22.2%; the positive predictive value was 76.4% and the negative predictive value was 30.8%. Using a cut-off point of AHI > 15, the sensitivity was 89.3% and the specificity was 22.6%; the positive predictive value was 42.1% and the negative predictive value was 76.9%. CONCLUSIONS: These findings indicate that BQ is a poor predictor of OSA in patients who are at high risk of OSA. The BQ does not appear to be an appropriate screening tool for determining the risk of sleep apnea in this population.

Comparison of the force required to fracture roots vertically after ultrasonic and Masserann removal of broken instruments.

AIM: To evaluate the force required to fracture roots vertically after the removal of broken instruments using ultrasonic tips and a Masserann kit. METHODOLOGY: Thirty-nine extracted human anterior teeth with single and straight roots were used. The crown of each tooth was removed until the full length of the tooth was 13 mm. All canals were instrumented with the step-back technique to a size 25 K-file. The teeth were randomly divided into three groups: two experimental groups and a control group. The size 30 K-files used for the test were notched to a depth of half of the instrument with a No. 2 round bur at a point 3 mm from the tip to facilitate breakage of the file at this point. The fractured instruments were removed from the canals using ultrasonic tips or a Masserann kit. The samples were subjected to a continual vertical loading, using a universal testing machine. For each root, the force at the time of fracture was recorded in Newtons. The results were analysed statistically using one-way anova and Tukey HSD test. RESULTS: The force required to fracture the roots vertically was significantly higher in the control group than the experimental groups (P < 0.01). The roots from which the broken instruments had been removed using ultrasonic tips required more force to fracture than roots in the Masserann group; however, the difference was not statistically significant. CONCLUSION: Removal of a fractured instrument from the middle third of the root decreased the force required to fracture the root vertically, regardless of the technique used for instrument removal. There was not difference between the ultrasonic technique and the Masserann technique.

Thyroglossal duct cysts: evaluation and treatment of 49 cases.

OBJECTIVE: The aim of the study was to evaluate the clinical features and treatment outcomes of patients with a thyroglossal duct cyst (TGDC) or fistula. METHODS: The records of 49 patients (9 female, 40 male; mean age: 23.16 +/- 1.13 years; range 6 to 56 years) operated on between January 1995 and July 2009 were reviewed retrospectively. Patient's age, sex, duration of symptoms, clinical features, pre-operative diagnostic tests, treatment, histopathologic diagnosis, and post-operative complications were noted. All patients underwent the Sistrunk procedure. RESULTS: Fifteen patients (30.6%) were < or = 20 years old, while 3 (6.1%) patients were 40 years old at the time of operation. There was cyst formation in 26 patients (53.1%) and fistula formation in 23 patients (46.9%). The lesions of 41 patients (83.7%) were located in the midline, while the lesions of 8 patients (16.3%) were located in the paramedian neck (5 left side, 3 right side). The most common presenting symptoms were painless mass in the midline of the neck and recurrent suppuration of fistula formation. Neck ultrasonography (USG) was the most common pre-operative diagnostic procedure and was performed on all patients with cyst formations. There were no major complications postoperatively. There was recurrence in only one patient after the Sistrunk procedure. One patient was incidentally diagnosed with thyroid papillary carcinoma after histopathological examination. CONCLUSIONS: A TGDC is the most common congenital mass in the neck and is usually located midline. USG is suggested for a clinically suspected TGDC. The Sistrunk procedure is a safe and successful technique with low complication and recurrence rates. Even though carcinomas arising in TGDCs are uncommon, histopathological examination must be routinely performed to confirm the diagnosis and rule out malignancy.

Significance of fascin expression in laryngeal squamous cell carcinoma.

OBJECTIVE: Fascin is an actin-binding protein which is expressed in the basal areas of healthy squamous epithelium. Although overexpression of fascin has been shown in many tumours, the relationship between fascin and laryngeal squamous cell carcinoma has not previously been investigated, to the best of our knowledge. This study aimed to investigate the relationship between fascin expression and tumour behaviour in 30 cases of laryngeal squamous cell carcinoma. MATERIALS AND METHODS: For all lesions, a section of paraffin-embedded tissue was immunohistochemically stained for fascin. The percentage of positive, stained cells was scored from one to five (one = 0-5 per cent, two = 6-25 per cent, three = 26-50 per cent, four = 51-75 per cent and five = 76-100 per cent), and the staining intensity from one to three (one = mild, two = moderate and three = strong). A total immunohistochemical fascin expression score was obtained by multiplying the staining percentage and intensity. The relationship between the total fascin score and each case's age, sex, tumour localisation, tumour-node-metastasis stage and differentiation was evaluated statistically. RESULTS: Various amounts of fascin expression were observed in all cases. There was a statistically significant relationship between high levels of fascin expression (i.e. a total fascin score of 10 or more) and the cases' tumour stage (p = 0.022), node stage (p = 0.024) and clinical stage (p = 0.014). In addition, worsening tumour differentiation was associated with an increasing fascin score, but this finding was statistically insignificant. CONCLUSION: These results suggest that laryngeal squamous cell carcinomas with high levels of fascin expression may be more aggressive than those with low expression levels. Further studies with larger series are needed to support these results and to clarify rationales.

Rosai Dorfman disease of the parotid and submandibular glands: salivary gland scintigraphy and oral findings in two siblings.

Rosai-Dorfman disease (RDD) is an unusual clinical entity characterized by benign pseudolymphomatous proliferation with significant histiocytic infiltration. In the present paper, extranodal RDD of the major salivary glands causing salivary hypofunction and the results of salivary gland scintigraphy and ultrasound are presented in two siblings. Case 1: a 10-year-old boy with bilateral painless masses around the parotid and submandibular glands was referred. Ultrasound examination showed bilateral, well-defined, hypoechoic solid mass lesions within both parotid glands with minimal normal parenchyma in the upper poles. Both submandibular glands were markedly hypoechoic and heterogeneous. Mass lesions within the parotid glands appeared as cold lesions with regular contours on scintigraphy. Dynamic images showed normal uptake and normal response to secretion in the upper poles of the parotid glands, corresponding with ultrasonographically normal parenchyma. Both submandibular glands showed markedly diminished uptake and secretion. Case 2: a 9-year-old boy presented with mass lesions around the submandibular glands. Ultrasound examination showed normal parotid glands and markedly hypoechoic and heterogeneous submandibular glands. Salivary gland scintigraphy showed normal uptake and secretion of parotid glands with markedly diminished uptake and secretion in both submandibular glands. There were severe carious lesions in both patients due to salivary hypofunction. Treatments of the two patients' teeth were performed. Major salivary gland involvement of RDD is important for dentists as it may cause xerostomia and can mimic dental abscess. Functional evaluation of salivary glands with scintigraphy, besides radiological and pathological techniques, will help to explain whether salivary glands are affected or not and improve the diagnostic effectiveness.

Analysis of different surgical approaches for the treatment of cerebrospinal fluid rhinorrhea.

The current treatment method for cerebrospinal fluid (CSF) rhinorrhea is surgical repair of the fistula. The aim of this study was to analyse different surgical approaches used for the treatment of CSF rhinorrhea regarding several preoperative and postoperative variables to determine the optimal method in these patients. Patients' charts were retrospectively reviewed to get the required data. Twenty-six patients who underwent different types of surgical approach for the treatment of CSF rhinorrhea were included in the study. Patients who had extensive comminuted fractures of the anterior cranial base and additional brain injury besides CSF rhinorrhea, mostly as a result of gunshot injuries, underwent craniotomy (n = 14). Osteoplastic frontal sinusotomy was used in two patients with a dural defect located at the posterior wall of the frontal sinus. Uncomplicated CSF fistulas in ten patients, located at the anterior and posterior ethmoid roof and in the sphenoid sinus, were closed with an endonasal endoscopic approach. Postoperative success rate was higher (97 % for intracranial approach, 100 % for extracranial external and endonasal endoscopic approach) for all techniques. Anosmia was the most frequent permanent complication (n = 5), seen after craniotomy. In conclusion, endonasal endoscopic approach can be preferred for the closure of uncomplicated CSF fistula, located at the anterior or posterior ethmoid roof and in the sphenoid sinus, due to its minimal postoperative morbidity. Uncomplicated CSF fistula, located at the posterior wall of frontal sinuses can be repaired extradurally with osteoplastic frontal sinusotomy. Intracranial approaches should be reserved for more complicated CSF rhinorrhea which results from extensive comminuted fractures of the anterior cranial base and is accompanied with intracranial complications.

Effects of allergen immunotherapy on the nasal mucosa in patients with allergic rhinitis.

Despite the varied immunological changes occurring after allergen immunotherapy, the precise mechanism, or the mechanisms responsible for clinical effectiveness of allergen immunotherapy have not been clearly determined. Postulated immunomodulatory mechanisms include a decrease in cellular responsiveness, a production of blocking antibodies, a reduction in the number of mast cells, and activation of T-cell suppressor mechanisms. Nineteen allergic rhinitis patients (study group) with house dust mite sensitivity and 10 nonallergic control subjects were studied. In the study group, the nasal mucosal biopsies were obtained prior to immunotherapy and were repeated after 1 year, and specimens were evaluated by light and electron microscopy. After the third month of immunotherapy, nasal symptom scores were reduced significantly and disappeared in the sixth month (p <0.01). No significant changes were observed in the levels of immunoglobulins, IgG subclasses and complement levels (p <0.05), except IgG4/IgG1 ratio (p <0.05). A comparison of histopathological findings of nasal mucosa in each case revealed an improvement in epithelial loss, inflammation, thickening of basal membrane and fibrosis (p <0.05). A significant correlation was observed between epithelial loss and mast cell accumulation with symptom score (p <0.001). These results suggest that the improvement of nasal epithelial cells and reduction of mast cell accumulation in nasal mucosa may be one of the mechanisms that could explain the improvement of nasal allergy symptoms following immunotherapy.

Nasal surgery for contact point headaches.

Headache due to the pressure on nasal mucosa of anatomical variations, nasal polyps, or mucosal swelling in the absence of inflammation of the paranasal sinuses is a clinical entity that has gained wide acceptance. In this paper, the outcomes of surgical treatment in 30 patients whose headaches were believed to be the result of intranasal contact points are presented. Total relief of the headache and significant improvement were achieved in 43% and 47% of the patients, respectively, after endoscopic endonasal surgery. The intensity of the headache was the same as preoperatively in 10% of the patients. In the absence of any other identifiable etiological factors, intranasal mucosal contacts must be kept in mind as a cause of the headache.

Radiology of an atypical fibro-osseous lesion confined to the nasal cavity.

Fibro-osseous lesions of the sinonasal region are relatively frequent, but those strictly confined to the nasal cavity are rare. We report an atypical fibro-osseous lesion in the nasal cavity and describe its radiological features. The differential diagnosis is discussed.

Antrochoanal polyps: analysis of 16 cases.

Antrochoanal polyps are rare lesions. Several surgical techniques have been reported to provide complete cure of the disease. However, inadequate treatment may result in a high rate of recurrences. The aetiological as well as predisposing factors are not well understood. We present a literature review and discuss the clinical, pathological and histological features of 16 patients with antrochoanal polyps, who have been surgically treated by either an endoscopical or conventional approach. It has been found that allergy has no role in the aetiology of antrochoanal polyps. However, the majority of the patients have sinonasal disease. The most common pre-operative radiological finding is the mucocoele-like appearance, which has also been confirmed in surgery. It is remarkable that antrochoanal polyps have recurred in 4 out of 8 patients, who have underwent simple intranasal polypectomy and inferior turbinectomy. As compared to conventional technique, the endoscopic approach proves to be superior.

Elongated styloid process: diagnostic problems related to symptomatology.

A certain number of patients with elongated styloid process may not have the classic cervicofacial complaints which were originally described by W. Eagle in 1937. Some of those cases who have radiologic evidence of elongated styloid process are symptom free and can be accepted as normal anatomical variants. On the other hand, some of those symptomatic cases may present uncommon neurologic signs and can be misdiagnosed as neurologic or infectious disease. Sometimes, the radiologic presence of an elongated process may cause the clinician to miss another pathology. Therefore, it is essential for the clinician to be aware of the clinical variants with different symptomatology or to particularly seek the origin of the pain in the head and neck before reaching a conclusion, since the only effective treatment in symptomatic cases is the surgical shortening of the process. We report five patients with elongated processes. Problems related to an elongated styloid process with different symptomatology are discussed and the associated literature is reviewed.

Effects of fibroblast growth factor on the healing process of tympanic membrane perforations in an animal model.

After traumatic perforation of the tympanic membrane (TM), healing occurs spontaneously in most cases, although occasional perforations will fail to close. Healing of epithelia at any site involves cell movement, with injury providing the stimulus to initiate changes in the behavior of cells that are normally static. Epidermal proliferation at the margins of the TM perforation can be accelerated by using such growth factors as epidermal growth factor, basic fibroblast growth factor (bFGF) and hyaluronan. bFGF is chemotactic and mitogenic for both fibroblasts and endothelial cells and is also mitogenic for keratinocytes. The effect of bFGF is significant in the enhancement of fibroblast production and angiogenesis. In this study, bFGF was used to enhance the healing process of chronic TM perforations in a guinea pig animal model. Chronic perforations were created since acute TMs could heal spontaneously without using any bioactive substance. In all, 30 TMs of 15 guinea pigs were used. A thermal myringotomy loop was employed to create a subtotal TM perforation at the area of the pars tensa. After establishing a permanent, non-infected perforation, bFGF in buffered saline solution was applied as 400 ng/day to 15 ears, while the opposite (control) ear was treated with only saline solution. At 20 days, 13 of 15 perforations treated with bFGF had closed. Light microscopy was used to assess organization of the healed TMs. The effects of bFGF on the healing process of TM perforations were compared in treated and non-treated ears.

Patient selection and surgical results in obstructive sleep apnea.

In recent years, therapeutic methods have been effective in the management of snoring and sleep apnea. Successful results have been possible through conservative and surgical approaches when the nature and site of obstruction is ascertained by careful investigation. Sagittal magnetic resonance imaging (MRI) of the upper respiratory tract has been the most valuable diagnostic tool in patients with obstructive sleep apnea. This has made it possible to measure the dimensions and distance of the hard and soft palate and tongue base to the posterior pharyngeal wall. Surgery is only indicated when a site of obstruction can be completely determined. In this study, surgical approaches and results obtained in 50 patients after surgery for sleep apnea are presented. Uvulopalatopharyngoplasty (UPPP) had a higher success rate in patients with obstruction at the level of the soft palate, but this rate decreased when it was associated with hypopharyngeal obstruction or when there was hypopharyngeal obstruction alone. UPPP was found to be beneficial in patients with central apnea. Nasal pathologies also played an important role in sleep apnea. Better results were obtained when UPPP was performed in patients who were young, not obese and an apnea-hypopnea index was below 40. Some unusual pathologies included lingual tonsil hypertrophy in the adult, sublingual dermoid cysts and angioma of soft palate and were found to be the cause of OSA. After surgical excision of these pathologies, apneic periods disappeared.