Chondromesenchymal Hamartoma With Nasopharyngeal Involvement: Two Unusual Cases of an Extremely Rare Lesion.

Chondromesenchymal hamartoma (CMH) is a rare, benign lesion of the nasal cavity, paranasal sinuses, and skull base, composed of islands of hyaline cartilage in a myxoid background. The vast majority of CMH cases are infants and young children. According to the world literature, nasopharyngeal involvement of CMH is extremely rare. In all cases, the lesions were masses protruding from the nasal cavity or paranasal sinuses to the nasopharynx. We hereby report 2 adult male patients with masses completely situated in the nasopharyngeal space. In the first patient, the tumor originated from the posterior edge of the nasal septum and in the second one, from the posterolateral wall of the nasopharynx, adjacent to the pharyngeal orifice of the Eustachian tube. In both patients, the lesion was excised endoscopically, and histopathological analyses were consistent with a diagnosis of CMH. To our knowledge, those are the only cases of CMH completely situated in the nasopharynx.

Giant Fibrovascular Polyp as an Unusual Cause of Globus Pharyngeus.

Differential diagnosis of globus sensation in an otherwise asymptomatic patient should include hypopharyngeal fibrovascular polyp to avoid potentially fatal complications like airway compromise following regurgitation. We present a case of a 74-year-old man with a 13-cm long hypopharyngeal fibrovascular polyp with 9 months history of globus sensation. A narrow stalk of the giant polyp allowed endoscopic removal and complete resection with the CO2 laser. Histopathological examination was conclusive for the fibrovascular polyp.

Occupational rhinitis caused by hypersensitivity to black pepper.

Black pepper (Piper nigrum) rarely leads to allergic inflammation of the nasal mucosa. This is a presentation of a 52-year-old female worker exposed to black pepper dust for 10 years suffering from allergic rhinitis and chronic rhinosinusitis. She complained of nasal obstruction, rhinorrhoea, and a weakened sense of smell. Clinical examination showed the bilateral presence of polypoid lesions arising from the middle turbinate. After surgery, histopathological examination confirmed the diagnosis of inflammatory nasal polyps. Duration of exposure to black pepper and serum concentration of specific immunoglobulin E antibodies indicating work-related exposure would support a causal link between exposure to these factors and the development of chronic inflammation in the nasal mucosa. Inflammatory nasal polyps may be noted in the nasal cavity in workers exposed to black pepper dust. The absence of exposure to black pepper resulted in no detectable circulating antibodies one year after the change of workplace.

Different levels of mucus inflammatory mediators in nasal polyposis with and without aeroallergen sensitivity.

Objectives: Biomarker levels in nasal secretions can reflect the inflammatory status of nasal mucosa and evolution of sinus disease. The aim of this study was to evaluate the relationship between local inflammatory mediator production and clinical characteristics of patients with nasal polyposis (NP). Methods: Thirty-one nonaeroallergen sensitized patients with NP (NANP), 29 aeroallergen sensitized patients with NP (ANP), and 30 subjects without inflammation of nasal mucosa as controls (C) entered this prospective, cross-sectional study. Clinical parameters (symptoms, endoscopic, and radiological findings) were assessed. The concentrations of heat shock protein 70 (HSP70), eosinophil cationic protein (ECP), tryptase, substance P and Clara cell protein 16 (CC16) were measured in the nasal secretion samples of all participants by ELISA method. Results: Our results showed higher concentrations of HSP70, ECP, and tryptase in ANP than in NANP and C (p < .001 for all markers). On the other hand, levels of CC16 were significantly higher in C than in NANP and ANP groups (p < .001; p < .001, respectively). We found positive correlations between HSP70, ECP, tryptase, and substance P levels and nasal symptom score in patients with NP. Also, HSP70, ECP, tryptase, and substance P showed different levels of positive correlation among themselves, with HSP70 showing highest positive correlation with ECP. Finally, relatively strong negative correlations were found between the levels of CC16 and nasal symptoms, as well as between the CC16 levels and levels of other four mediators in nasal fluid. Conclusion: HSP70, ECP, tryptase, and substance P might play a role in the pathogenesis of NP. The results suggest that chronic inflammation in NP involves a self-sustaining local release of HSP70, ECP, and tryptase, independent of aeroallergen stimulation of the mucosal layer, although the production of these mediators is higher in aeroallergen sensitized NP patients.

Angiomyolipoma Originating From the Nasal Vestibule: A Case Report.

Angiomyolipoma is a benign, mesenchymal, hamartomatous lesion often described in the kidney and may be associated with tuberous sclerosis. Nasal angiomyolipoma is an extremely rare tumor with fewer than 20 cases reported in the literature. We report a case of angiomyolipoma arising in the right nasal vestibule in a 68-year-old male with mild, recurrent right-sided epistaxis, and nasal obstruction. With the exception of arterial hypertension, the patient did not have any comorbidities. Gross examination showed a well-circumscribed, lobulated mass. On the microscopic level, it was composed of mature smooth muscle cells, thick-walled blood vessels of varying sizes, and islands of mature adipose tissue. Angiomyolipoma should be considered as a differential diagnosis for unilateral nasal masses, especially those situated in the nasal vestibule.

Herbal Drug EPs 7630 versus Amoxicillin in Patients with Uncomplicated Acute Bacterial Rhinosinusitis: A Randomized, Open-Label Study.

OBJECTIVE: Previous investigations suggest the use of extract from the root of Pelargonium sidoides (EPs 7630) for the therapy of uncomplicated acute upper airway inflammations, due to its strong antimicrobial and immunomodulatory effect. We aimed to compare clinical efficacy, safety and bactericidal effect of EPs 7630 and amoxicillin monotherapy in treatment of patients with mild to moderate acute bacterial rhinosinusitis (ABRS). METHODS: Fifty ABRS patients were divided into two groups by randomization. Group 1 (n = 25) received EPs 7630 tablets, 3 × 20 mg/day per os for 10 days. Group 2 (n = 25) received amoxicillin tablets 3 × 500 mg/day per os, for 10 days. We assessed total symptom score (TSS), individual symptom scores for each symptom (nasal obstruction, rhinorrhea, postnasal drip, facial pain/pressure, loss of the sense of smell), endoscopic findings, including total endoscopic score (TES) and individual endoscopic signs (mucosal edema, mucopurulent secretion), before and after treatment. Samples of discharge taken from the middle meatus of all patients were cultivated for bacteria before and after therapy. RESULTS: Higher absolute improvement after treatment was found for TSS, nasal obstruction, facial pain/pressure, impaired sense of smell, TES, mucosal edema and mucopurulent secretion in EPs 7630 group compared to amoxicillin group (P < .001 for all parameters). However, there were no differences in absolute improvement of rhinorrhea score and postnasal drip score between groups (P = .248; P = .679, respectively). Fewer types of bacteria grew on culture from middle meatal samples in EPs 7630 group compared to amoxicillin group. There were no reported adverse events from patients from either group. CONCLUSION: Our results demonstrated better clinical and antimicrobial efficacy of EPs 7630 than amoxicillin. EPs 7630 was shown as a potent agent and good alternative to antibiotic treatment of uncomplicated ABRS.

Association of locally produced IL10 and TGFb1 with tumor size, histological type and presence of metastases in patients with lung carcinoma.

PURPOSE: Advanced lung carcinoma is charasterized with fast disease progression. Interleukin (IL)10 and transforming growth factor (TGF)b1 are immunosuppressive mediators and their role in lung carcinoma pathogenesis and in the antitumor response has not yet been elucidated. The purpose of this study was to correlate IL10 and TGFb1 levels in the serum and lung tumor microcirculation with clinical stage, disease extent, histological features and TNM stage. METHODS: The study included 41 lung cancer patients in clinical stage III and IV. Histological type was determined immunohistochemically, while tumor size, localization and dissemination were determined radiologically by multislice computerized tomography (MSCT). IL10 and TGFb1 levels were quantified with commercial flow cytometric test in serum and lung tumor microcirculation samples. RESULTS: Non small cell lung cancer (NSCLC) patients had significantly elevated TGFb1 while small cell lung cancer (SCLC) patients had significantly increased IL10 in tumor microcirculation. IL10 was significantly elevated in patients with the largest tumors, as well as in patients with III clinical stage and without metastases, both in the serum and tumor microcirculation. TGFb1 was significantly increased in serum and tumor microcirculation in patients with larger tumors. We found significant correlation between these two immunosuppressive cytokines, IL10 and TGFb1, in tumor microcirculation but not in patient serum samples. CONCLUSION: IL10 and TGFb1 in systemic and tumor microcirculation are significantly associated with particular histological type of lung cancer, tumor size and degree of disease extent.

Adaptation and Validation of the Voice Handicap Index (VHI)-30 into Serbian.

OBJECTIVES: To evaluate the internal consistency, test-retest reliability, and clinical validity of the Serbian version of the self-administered Voice Handicap Index (VHI)-30. STUDY DESIGN: Cross-sectional study. METHODS: The English version of VHI-30 was translated into Serbian and then back-translated into English. The Serbian VHI-30 was administered to 91 patients divided into four groups according to voice pathology: structural, inflammatory, neurologic, and functional groups. The control group included 90 subjects with no voice problems. The internal consistency (Cronbach's alpha coefficient α), test-retest reliability (interclass correlation coefficient) of VHI-30, comparison of patient's and control's VHI-30 scores (Mann-Whitney U test; Kruskal-Wallis test), and correlation with overall severity of dysphonia (Spearman correlation coefficient, ρ) were calculated. RESULTS: In the patient group, we observed excellent internal consistency for the Serbian VHI-30 (α = 0.95) and good internal consistency for all VHI-30 subscales: physical (α = 0.88), functional (α = 0.88), and emotional (α = 0.88). The interclass correlation coefficient indicated strong test-retest reliability for patients (0.99) and controls (0.84). The mean scores of all 30 items in dysphonic participants were significantly higher than in controls (P < 0.001). Good correlation was obtained between the total scores of VHI-30 and patients' self-perceived overall severity of dysphonia (ρ = 0.748, P < 0.001). Within the patient group, the female participants displayed significantly higher VHI-30 scores than male participants (Mann-Whitney U test, P < 0.001). The VHI-30 scores showed strong correlation within different patient groups and controls (Spearman correlation coefficient: structural, 0.942; inflammatory, 0.756; neurologic, 0.888; functional, 0.982; controls, 0.882). CONCLUSIONS: The Serbian VHI-30 is a useful and valuable tool for the evaluation of patients with vocal disorders and for making subsequent clinical decisions.

Nonselective chemokine levels in nasal secretions of patients with perennial nonallergic and allergic rhinitis.

BACKGROUND: An increased production of several chemoattractants, responsible for guiding the eosinophilic inflammatory process, has been reported in chronic rhinitis. The aim of this study was to evaluate nasal secretion levels of monocyte chemoattractant protein-1 (MCP-1), MCP-3, and regulated on activation normal T cell expressed and secreted (RANTES) and to correlate those levels with nasal symptoms and degree of eosinophilia in patients with nonallergic rhinitis with eosinophilia syndrome (NARES) and perennial allergic rhinitis (PAR). METHODS: Fourteen patients with PAR and 14 NARES patients were recruited for this cross-sectional study. Fourteen healthy subjects were included as controls. The concentrations of MCP-1, MCP-3, and RANTES in nasal secretions were measured using enzyme-linked immunosorbent assay (ELISA). Eosinophil counts were performed by percentage of differential granulocyte counts during cytological examination of scraped nasal mucosa obtained from the inferior turbinate. Therefore, we scored rhinitis patients according to nasal symptom score. RESULTS: We found significantly higher concentrations of MCP-1 (p < 0.0001), MCP-3 (p = 0.018), and RANTES (p < 0.0001) in nasal fluid of NARES patients compared to patients with PAR. In PAR patients, we found positive correlation between RANTES levels and nasal symptom score and eosinophil counts. In patients with NARES, the concentrations of MCP-1 and RANTES were associated with nasal symptom score and percentage of eosinophils. CONCLUSION: NARES is characterized by higher degree of eosinophilic inflammation than PAR. RANTES correlates well with the level of eosinophilic inflammation in both diseases. The measurement of chemokine levels in nasal secretions could be useful in evaluating the degree of chronic nasal inflammation.

Risk factors for surgical site infection in laryngeal cancer surgery.

Surgical site infection (SSI) is a significant factor of morbidity and mortality in patients surgically treated for laryngeal carcinoma. The aim of this prospective study in 277 patients was to determine the incidence of SSI in patients surgically treated for laryngeal squamous cell carcinoma and to identify risk factors for development of SSI. Patients with previous chemotherapy and/or radiotherapy were excluded. All patients had tracheostomy postoperatively and received antibiotic prophylaxis with cephalosporin, aminoglycoside and metronidazole. The overall incidence of SSIs in our cohort was 6.5% (18 patients): 4 (22.22%) patients with superficial infections, 11 (61.11%) with deep infections and 3 (16.66%) with organ-space infections. The remaining infections included pneumonia (1 case) and Clostridium difficile colitis (2 cases). The median hospital stay in patients having developed SSIs was longer than in those without SSIs (33.5 vs. 16 days, p < 0.001). By using univariate analysis American Society of Anesthesiologists score > 3, duration of surgery longer than 120 minutes and National Nosocomial Infections Surveillance risk index > 1 were found to be significantly associated with the occurrence of SSI. Age, sex, body mass index, history of smoking, underlying diabetes and preoperative length of stay were found not to be associated with SSI. The most frequently isolated microorganism was Klebsiella spp.

Macrophage inflammatory protein-1 production and eosinophil infiltration in chronic rhinosinusitis with nasal polyps.

OBJECTIVE: Eosinophil recruitment to the nasal mucosa involves a number of chemokines. The aim of this study was to evaluate nasal secretion levels of macrophage inflammatory protein-1 alpha (MIP-1α) and MIP-1ß and to correlate these levels with clinical characteristics and degree of eosinophilia in nonallergic and allergic patients with nasal polyposis (NP). METHODS: Fourteen nonatopic and 14 atopic patients with NP were recruited for this cross-sectional study. Fourteen healthy subjects were included as controls. The concentrations of MIP-1α and MIP-1ß in nasal secretions were measured by flow cytometry. Eosinophil counts were performed by cytological examination of the scraped nasal mucosa. We scored each of the 28 patients according to the nasal symptom score, endoscopic score, and computed tomography (CT) score. RESULTS: We found significantly higher concentrations of MIP-1α in nasal fluid of nonallergic and allergic NP patients compared to control subjects. In nonallergic patients, we found positive correlations between MIP-1α levels and endoscopic score, CT score, and the percentage of eosinophils. CONCLUSION: MIP-1α may play a role in eosinophil recruitment in NP. Our results suggest that the measurement of MIP-1α in nasal secretions could be useful in evaluating the degree of eosinophil inflammation and severity of disease in nonallergic patients.

Recurrent lipomatous tumor of hypopharynx: case report and literature review.

Liposarcoma is one of the most common soft-tissue sarcomas in adults, but head and neck are rarely involved, especially regions of the larynx and hypopharynx. According to Enzinger and Weiss, liposarcoma can be divided into 5 subtypes: well-differentiated, myxoid, round cell, pleomorphic and dedifferentiated. We present an unusual case of well-differentiated liposarcoma of the hypopharynx in a patient with previous three procedures of endoscopic removal of hypopharyngeal tumor classified as benign lipoma. Well-differentiated liposarcoma is a tumor of low-grade malignancy, which frequently recurs locally, but does not metastasize. Wide tumor resection with free margins is mandatory. Immunohistochemistry is a useful diagnostic tool. We also discuss recently published literature on this unusual presentation of well-differentiated liposarcoma.

Immunohistochemistry in diagnosis of extranasopharyngeal angiofibroma originating from nasal cavity: case presentation and review of the literature.

Angiofibromas are rare vascular tumors which originate predominantly in the nasopharynx and occur typically in male adolescents. Extranasopharyngeal sites such as nasal cavity and paranasal sinuses are less frequent. This review article was undertaken to evaluate the incidence, clinical features and management of extranasopharyngeal angiofibromas originating exclusivelly from nasal cavity structures. Our focus of interest was to evaluate the significance of immunohistochemical analysis in diagnosis of such extremely rare neoplasms. In the PubMed and Google Search, we found only 39 cases of nasal angifibroma, 27 males and 12 females from 1980 to 2012. The most prevalent site of origin was nasal septum, followed by inferior and middle turbinate. The commonest symptoms were nasal obstruction and epistaxis. Nasal angiofibromas are clinically distinct from nasopharyneal angiofibromas and can therefore be misdiagnosed. The differential diagnosis includes other vascular lesions, such as lobular capillary hemangioma and sinonasal-type hemangiopericytoma. Although immunohistochemistry is not necessary for differentiation between angiofibroma and capillary hemangioma, that diagnostic procedure may be helpful in distinction from sinonasal hemangiopericytoma. As an ilustration for immunohistochemical analysis, we presented a case of an elderly woman with tumor arising from the middle turbinate, diagnosed as angiofibroma. The staining was positive for CD34, CD31, factor VIII, vimentin and smooth muscle alpha-actin, and negative for desmin.

Early postoperative complications in children with secretory otitis media after tympanostomy tube insertion in the Military Medical Academy during 2000-2009.

BACKGROUND/AIM: Secretory otitis media (SOM) is a chronic, nonpurulent inflammation of the middle ear, characterized by a long-term presence of liquids of different density in the middle ear for at least three consecutive months, different degrees of hearing loss and the absence of perforation of the eardrum. The aim of this study was to estimate the early postoperative complications after insertion of tympanostomy tube (TT) in children with secretory otitis media (SOM) in an 18-month period after TT insertion. METHODS: This retrospective study included children with SOM (n = 478), aged from 2.5 to 16 years, operated from 2000 to 2009. During these ten years 365 children had TT in both ears, 131 children had TT in one ear and 55 children were operated two or more times. Totally 843 ears were operated on. Date were obtained by regular fallow up in Out-patient clinic concerning symptoms reported by children and parents, otomicroscopy findings and hearing measurements (audiometry and tympanometry). RESULTS: Transient otorrhea was the most common early postoperative complication (16.5%), then obstruction (9.5%), premature extrusion of TT (3.9%), chronic otorrhea (3.1%), granulation tissue (1.1%) and medial displacement (0.5%). According to our experience gold and silicone TT were shown less successful than others. The incidence of premature extrusion of TT was significantly higher with gold TT, comparing to others (6/33, 18%; p < 0.001). We also found significantly more frequent medial displacement with silicone TT than with other ones (2/4, 50%; p < 0.001). CONCLUSION: There are many early postoperative complications of TT insertion, but they depend on the meticulous surgery techniques, regular postoperative examinations and the type of TT. The type of TT should be determined according to own experience.

Avascular necrosis of stapes crura in one case of operated otosclerosis.

Unilateral otosclerosis combined with avascular necrosis of stapes crura is a rare entity. It should be considered in a case of high grade otosclerosis. Symptoms are the same as in patients who suffer from common otosclerosis. Patients complain on progressive hearing loss and tinnitus. The diagnosis is made clinically by conventional audiologic evaluation and radiologically by x-ray mastoid Schuller's view and CT scan. HRCT scan makes visible all parts of ossicular chain and gives surgeon some information about ossicular chain damage. Surgery with stapedotomy and stapes prosthesis implantation in a case of otosclerosis with avascular necrosis of stapes crura can be success therapy to improve patient's hearing

[Endoscopic dacryocystorhinostomy].

BACKGROUND/AIM: Intensive epiphora (lacrimal apparatus disease) can make difficult daily routine and cause ocular refraction disturbances. In most cases ethiology is unknown, rarely occurs after nose surgical procedures, face fractures, in Wegener granulomatosis, sarcoidosis and malignancies. The aim of this study was to evaluate efficacy of endonasal endoscopic surgical procedure with the conventional surgical instruments in treatment of nasolacrimal obstructions. METHODS: This retrospective study included 12 female patients with endonasal endoscopic surgical procedure from Otorhinological and Ophtalmological Departments of Military Medical Academy, Belgrade from September 2007 to April 2009. Preoperative nasal endoscopy was performed in order to reveal concomitant pathological conditions and anatomic anomalies which could make surgical procedure impossible. Computerized tomography was performed only in suspect nose diseases. Surgical endonasal endoscopic procedure was performed by otorhinolaryngologist and ophtalmologist in all patients. The patients had regular controls from 2 to 20 months. RESULTS: A total of 12 female patients, age 34-83 years, were included in our study. Epiphora was a dominant symptom in all patients. In two patients deviation of nasal septum was found, and in other one conha bulosa at the same side as chronic dacryocystitis. All patients were subjected to endonasal dacryocystorhinostomy (DCR) by endoscopic surgical technique using conventional instruments. Concomitantly with DCR septoplastics in two patients and lateral lamictetomy in one patient were performed. There were no complications intraoperatively as well as in the immediate postoperative course. In two patients the need for reoperation occured. CONCLUSION: Endoscopic DCR is minimally invasive and efficaceous procedure for nasolacrymal obstructions performed by otorhinolaryngologist and ophtalmologist. Postoperative recovery is very fast.

Endoscopic middle meatal antrostomy in treatment of maxillary sinus mucoceles.

BACKGROUND/AIM: Mucocele of a paranasal sinus is a benign non-neoplastic condition characterized by cystic expansion and distension of the sinus cavity by retained mucoid secretions. Etiology is unknown. The purpose of this study was to estimate the efficiency of the endoscopic middle meatal antrostomy (MMA) as a treatment modality in patients with maxillary sinus mucoceles. METHODS: This retrospective study involved 11 patients with maxillary sinus mucoceles/pyoceles treated endoscopically in the Clinic for Otorhinolaryngology of Military Medical Academy, Belgrade over a 3-year period (2005-2007). The presented symptoms and signs, radiological and pathohistological findings and surgical treatment were reviewed. RESULTS: There were four females and seven males, age 22 to 65 years (mean 33 years). Two patients were with allergic rhinitis. All the patients complained of nasal obstruction, ten had facial pain, seven had nasal discharge, five had cheek pressure, and four had epiphora, and four had headaches. On endoscopic nasal examination, the medial wall of the maxillary sinus was bulging in ten patients. Purulent drainage was seen in eight patients, septal deviation in ten, and polyps were found in two of the patients. The MMA and marsupialization of the mucocele were performed in all the patients. On histopathological examination, the mucocele wall showed a lining composed of respiratory epithelium. Postoperative follow-up ranged between 8 and 44 months (in six patients, it ranged from 24 to 44 months). No patients required revision surgery. CONCLUSION: The MMA with mucocele marsupialization abolishes middle meatal obstruction and establishes better drainage and ventilation of the maxillary sinus and restitution of its mucosa.

[Concha bullosa and the nasal middle meatus obstructive syndrome].

BACKGROUND: Concha bullosa (CB) is pneumatization of the middle turbinate and one of the most common anatomic variation of the sinonasal region. It is found in about 25% of the population. Middle meatus obstructive syndrome (MMOS) is, usually connected with CB. The main symptoms of this syndrome are headaches, impaired nasal breathing and hyposmia. Headache is the most common symptom and it may occur due to contact between a CB and other structures of the nasal cavity. CASE REPORT: We presented a case of 32 year-old-woman with headaches, located in the orbital and the left frontal region. The headaches were intermittent and corresponding to the nasal cycle. After neurologic and allergic examination, endoscopic nasal examination demonstrated a septal deviation to the right side and a large middle turbinate in the left side of the nasal cavity. Coronal computerized tomography (CT) of the paranasal sinuses demonstrated the septal deformation and pneumatization of the left middle turbinate. Diagnosis was confirmed by lidocaine test. In the functional endoscopic surgery (FESS), the lateral lamela of the anterior CB was removed. At the same time, the septoplasty was done. At the control examination, the patient was without symptoms. CONCLUSION: Although CB is the common anatomic variation of the nasal cavity, MMOS is rare. Headache (rhinogenic origin) is the most important symptom. Surgical treatment is the lateral resection of the CB in the FESS technique and the septoplasty.