Relationships among retropalatal airway, pharyngeal length, and craniofacial structures determined by magnetic resonance imaging in patients with obstructive sleep apnea.

BACKGROUND: The integration of anatomical and nonanatomical parameters will improve our ability to predict the outcomes of OSA treatment. Currently, no standardized, quantitative classification of upper airway anatomical traits is available. The retropalatal (RP) airway is the most important area to consider when planning anatomical treatment. However, current evaluation methods feature qualitative conventional endoscopy. Here, we describe a quantitative magnetic resonance imaging (MRI) method used to classify RP airway patterns. METHODS: We recruited 117 males; 20 simple snorers and 97 patients with OSA. Lateral/anteroposterior ratios were calculated in three parallel planes and RP patterns were classified accordingly. Lateral wall soft tissue structures, skeletal dimensions representing those planes, pharyngeal lengths, and skeletal and vertical axis ratios were also measured. RESULTS: Both the cross-sectional area at the hard palate level and the RP lateral dimension were associated with OSA. OSA patients had longer pharynges than controls. The oblique pattern was associated with narrow lateral dimensions. The vertical pattern was associated with a narrow nasopharynx but a longer pharynx. The airway ratio at the hard palate level and the skeletal ratios of all three planes were negatively correlated with the vertical axis ratio and together explained 40.8% of the variance in the vertical axis ratio. CONCLUSIONS: The data suggest that anatomical imbalances between the craniofacial skeletal and soft tissue structures affect pharyngeal airway morphology in all three dimensions. The dimensions of the nasopharynx, the cross-sectional area at the hard palate level, and pharyngeal length were associated not only with the RP patterns but also with OSA severity. This study affords insights into upper airway anatomy and RP patterns and may help diagnose OSA patients and aid in the selection of an appropriate therapy.

Shrinkage of Nasal Mucosa and Cartilage During Formalin Fixation.

BACKGROUND: After resection, specimens are subjected to formalin fixation during histological processing. This procedure can result in tissue shrinkage, with the amount of shrinkage related to tissue composition and tissue type. AIMS: To evaluate the shrinkage of nasal mucosa and cartilage tissue and compare differences in shrinkage after resection, after formalin fixation, and during microscopic examination to understand differences in the rate of shrinkage of different tissue types. STUDY DESIGN: Animal experimentation. METHODS: Fresh nasal septa were excised from sheep (10 mm diameter in 40 sheep and 20 mm diameter in 40 sheep). The mucosa was separated from one side of the cartilage, with the contralateral mucosa remaining attached to the cartilage. Specimen diameters were measured in situ, after resection, after fixation for 6 or 24 hours (10% formalin), and during microscopic examination. RESULTS: There were no differences between the in situ and after resection diameters of any tissue components (free mucosa, mucosa attached to cartilage, and cartilage) of all nasal specimens (10- or 20-mm diameter and 6- or 24-hour fixation). However, significant shrinkage occurred between resection and after-fixation. Regarding tissue specimens that were fixed for different durations (6 or 24 hours), we observed a significantly smaller mean tissue diameter in specimens fixed for 24 hours versus those fixed for 6 hours for mucosa attached to cartilage (in the 10-mm diameter after-fixation samples), free mucosa (in the 20-mm diameter after-fixation samples), mucosa attached to cartilage (in the 20-mm diameter after-fixation and microscopic measurement samples), and cartilage (in the 20-mm diameter after-fixation samples). Tissue shrinkage was greatest in free mucosal tissue and least in cartilage. CONCLUSION: These results should be considered when evaluating patients undergoing surgical procedures for nasal cavity and paranasal sinus malignancies. Surgical margins should be measured before fixation or evaluated if possible before fixation and shrinkage.

Hypoxia and inflammation indicate significant differences in the severity of obstructive sleep apnea within similar apnea-hypopnea index groups.

PURPOSE: We determined whether hypoxia parameters are associated with C-reactive protein (CRP), mean platelet volume (MPV), white matter hyperintensity (WMH), and the severity of obstructive sleep apnea (OSA), and also evaluated whether hypoxia parameters, CRP, MPV, and WMH differ in patients with similar apnea-hypopnea index (AHI) scores. METHODS: A total of 297 patients, who were evaluated using polysomnography, were assessed retrospectively. The measured hypoxia parameters included total sleep time with oxygen saturation <90% (ST90), percentage of cumulative time with oxygen saturation <90% (CT90), and lowest oxygen saturation (min SaO2). The patients were divided into subgroups according to their CT90 values, and patients with different AHI severities were divided into subgroups according to their ST90 and min SaO2 levels. RESULTS: Hypoxia parameters are associated with CRP, MPV, WMH, and the severity of OSA (P < 0.05). The hypoxia parameters differed in all subgroup analyses of similar AHI groups (P < 0.001), and CRP differed only in severe OSA (P < 0.008, P < 0.001). In subgroup analyses of similar AHI groups, MPV and WMH were not significantly different (P > 0.05). Above the hypoxia threshold (CT90 ≥ 10%) of CRP, MPV increased significantly and the presence of WMH increased twofold. CONCLUSIONS: These data suggest that increased hypoxia severity may mediate increased inflammation and activation of platelets and contribute to the pathogenesis of WMH in patients with OSA. In addition, patients with severe OSA may show significant variability in inflammation and vascular risk. Further prospective data are needed.

[The relationship between passive rhinomanometry measurements in sitting and supine position and obstructive sleep apnea syndrome]. / Oturur ve sirtüstü pozisyonda pasif rinomanometri ölçümleri ve tikayici uyku apne sendromu ile iliskisi.

OBJECTIVES: This study aims to investigate the possible relationship between passive rhinomanometry measurements in sitting and supine position and obstructive sleep apnea syndrome. PATIENTS AND METHODS: Between January 2011 and December 2013, 88 male patients (mean age 46.8 years; range 18 to 79 years) underwent passive rhinomanometry in sitting and supine position following history, physical examination and fiberoptic endoscopic examination. 1.5 lt/sn air flow was pumped into the nose of each patient via a silicone nasal mask. Meanwhile, flow and pressure values were measured. RESULTS: There was no correlation between the resistance values and apnea hypopnea index (AHI) scores and polysomnography and physical examination parameters (p>0.05). The differential resistance was correlated with AHI (r=0.325, p<0.05), body mass index (r=0.324, p<0.05), neck circumference (r=0.421, p<0.01), waist circumference (r=0.444, p<0.01), modified Mallampati score (r=0.356, p<0.05), and retropalatal grade (r=0.438, p<0.01). CONCLUSION: The correlation between the differential resistance and physical examination parameters and AHI scores support the hypothesis that position-related retropalatal segment alterations can be measured by passive rhinomanometry while awake.

Sex differences in adult craniofacial parameters.

PURPOSE: To compare normal male and female craniofacial parameters in adults and evaluate associations of sex and intercochlear distance with other craniofacial parameters. METHODS: In 60 normal adults (30 men and 30 women) who had no otitis media, craniofacial parameters were measured retrospectively on two-dimensional reformatted computed tomography scans. RESULTS: Compared with women, men had significantly greater mean osseous auditory tube length, cartilaginous auditory tube length, mastoid length, intercochlear distance, sella to posterior nasal spine distance, sella to basion distance, and nasopharynx sagittal area. The intercochlear distance was significantly correlated with mastoid depth, midpoint of the pharyngeal opening distance, sella to nasion distance, and nasopharynx sagittal area and inversely with angle of the auditory tube. Most men and women had Körner septum present, and mean thickness of Körner septum was significantly greater in men than women. CONCLUSIONS: Some craniofacial parameters, especially vertical parameters, differ with sex. These differences begin in childhood and continue in adulthood. Sex must be considered when planning a craniofacial morphologic study, and results of a craniofacial morphologic study should be evaluated with caution when there is no sex matching of the patient and control groups.

Idiopathic incus necrosis: Analysis of 4 cases.

We evaluated ossicular chain reconstruction in patients with idiopathic incus necrosis who have conductive hearing loss and an intact ear drum. The study included four patients (3 women and 1 man; the ages of the patients were 22, 31, 35, and 56 years, respectively) with unilateral conductive hearing loss, no history of chronic serous otitis media, an intact ear drum, normal middle ear mucosa, and necrosis of the long processes of the incus. On preoperative pure tone audiometry, air-bone gaps were 24, 25, 38, and 33 dB. Bilateral tympanometry and temporal bone computed tomography results were normal. All 4 patients underwent an exploratory tympanotomy. During the operation, the mucosa of the middle ear was normal, with a mobile stapes foot plate and malleus. No evidence of any granulation tissue was found; however, necrosis of the incus long processes was seen. For ossicular reconstruction, we used tragal cartilage between the incus and the stapes in 1 patient; in the other 3 patients, glass ionomer bone cement was used (an interposition cartilage graft also was used in the patients who received the glass ionomer bone cement). In all patients, air-bone gaps under 20 dB were established in the first year after surgery. In the ossicular disorders within the middle ear, the incus is the most commonly affected ossicle. While, the most common cause of these disorders is chronic otitis media, it may be idiopathic rarely. Several ossicular reconstruction techniques have been used to repair incudostapedial discontinuity.

Focal Amyloidosis of the Orbit Presenting as a Mass: MRI and CT Features.

Focal orbital amyloidosis is a rare entity and little is known about its magnetic resonance imaging (MRI) features. In this case report, imaging features of a case of focal orbital amyloidosis presenting as a mass have been documented together with its histopathological findings. On MRI, a well-defined mass was seen as isointense with rectus muscle on T1-weighted images and heterogeneously hypointense on T2-weighted images. Punctuate calcifications were observed on the computerized tomography (CT) examination.

Craniofacial measures of chronic otitis media patients by 2D reformatted CT.

Few authors have studied differences in craniofacial morphology of adults with chronic otitis media (COM). We sought to compare the craniofacial measurements of patients with COM with otherwise healthy adults. The study group included 120 adult patients. The control group had 30 men and 30 women without evidence of otitis media; a COM group consisted of 30 men and 30 women with COM. Craniofacial measurements were assessed retrospectively using a two-dimensional reformatted CT method. Multiple linear (bony and cartilaginous auditory tube length, size of the mastoid, height of the jugular bulbus, intercochlear distance, bitemporal distance, distance between pharyngeal orifices, and some cephalometric cranial base distances), angular (auditory tube angle, cranial base angle), and area (axial and sagittal nasopharynx size) measurements were performed. In addition, petrosquamosal (Körner's) septum prevalence and size were evaluated. No statistically significant differences were found regarding craniofacial variables except mastoid size (mastoid depth and length). None of the craniofacial parameters showed significant differences between adults with COM and adults without evidence of otitis media, when age, sex, and race were considered. No statistically significant differences were found when mastoid size was compared with unilateral and bilateral COM. No statistically significant difference was found between mastoid size of the intact side and involved side of the unilateral patients with COM. Patients with unilateral and bilateral COM may be in the same group, genetically or environmentally, as far as mastoid size is concerned. Small mastoid size correlates with COM, but development of clinical disease should be under the control of different factors.

Long-term follow-up of patients with posterior canal benign paroxysmal positional vertigo.

CONCLUSIONS: Recurrence of posterior canal benign paroxysmal positional vertigo (PC-BPPV) developed in one-third of patients when followed for an average of 5 years from diagnosis. History of head trauma and Ménière's disease contributed significantly to recurrence (p < 0.05). History of head trauma as an etiologic cause was more frequent in patients with recurrence of PC-BPPV. OBJECTIVES: To estimate recurrence in the long-term follow-up of patients with PC-BPPV after successful canalith repositioning maneuvers, and to determine which factors contribute to recurrence. METHODS: The charts of 118 patients with PC-BPPV were reviewed. Data of patients were recorded from the initial evaluation and treatment. Follow-up was performed at mean of 64 +/- 7.7 months after the initial phase. The Dix-Hallpike maneuver was performed for diagnosis, and all patients were treated by the canalith repositioning maneuver, which was repeated every 3 days until the patients were symptom-free or results of the Dix-Hallpike maneuver were negative. RESULTS: At diagnosis, the most common etiology was idiopathic in 55 patients (46.6%). Recurrence occurred in 39 of 118 patients (33.1%). Recurrence occurred within the first 2 years in 21 of the 39 patients (53.8%). History of head trauma was a more frequent finding in patients who developed recurrence (12 of 39, 30.8%).

The metaplastic variant of Warthin tumor of the parotid gland: dynamic multislice computerized tomography and magnetic resonance imaging findings with histopathologic correlation in a case.

Metaplastic Warthin tumor is a rarely seen subtype of Warthin tumor. It can resemble squamous carcinomas histopathologically, because it contains atypical squamous cells on the necrotic surface. Making a diagnosis can become easier by knowing this entity of Warthin tumor well and by correlating the radiologic findings with pathology. In this case presentation, imaging features of a metaplastic Warthin tumor are presented together with its histopathologic findings. When a solid mass with peripheral enhancing cystic-necrotic component and well defined contour and capsule that shows early enhancement and washout is identified with imaging methods in parotid gland, metaplastic Warthin tumor should be indicated in the differential diagnosis before the histopathologic evaluation.

[Bilateral cerebellopontine angle lipoma in an asymptomatic patient: a case report]. / Asemptomatik hastada iki tarafli serebellopontin kösede lipom: Olgu sunumu.

We present here an asymptomatic case of a bilateral cerebello-pontine angle lipoma incidentally diagnosed by magnetic resonance imaging. Intracranial lipomas are rare and comprise just 0.1-1.5% of all intracranial tumors, and are mostly located in the corpus callosum. Cerebello-pontine angle (CPA) or internal acoustic canal (IAC) locations, on the other hand, are rather rare, and usually unilateral. Bilateral locations, as with the case presented here, were reported in only three cases in the literature. Cerebello-pontine angle and IAC lipomas typically infiltrate the neighboring cranial nerves (5, 7 and 8), causing progressive neurological deficits in 95% of cases. However, cases of bilateral CPA/IAC lipomas similar to this case are interesting because of their being asymptomatic.

[Endoscopic treatment of idiopathic spontaneous although cerebrospinal fluid rhinorrhea: a case report]. / Idyopatik spontan beyin omurilik sivisi rinorenin endoskopik tedavisi: Olgu sunumu.

Although cerebrospinal fluid (CSF) rhinorrhea is a rarely seen clinical entity, it is a condition which should be considered carefully by otolaryngologists and neurosurgeons because it has the possibility of serious complications unless it is treated. Trauma is the most common causative factor. Idiopathic spontaneous CSF rhinorrhea is a very rare entity which is difficult to manage and which has high recurrence rates. Although in the past CSF rhinorrhea used to be treated by intracranial route, nowadays endonasal endoscopic surgery is preferred because of wide usage of rigid endoscopes with much fewer complications, In this article, a case of 43-year-old female with idiopathic spontaneous CSF rhinorrhea repaired by endonasal endoscopic surgery is presented, and the diagnosis and the treatment of CSF rhinorrhea is reviewed.

Comparison of surgical outcomes of endonasal dacryocystorhinostomy with or without mucosal flaps.

OBJECTIVE: The goals of this study were to evaluate the long-term results of endoscopic endonasal dacryocystorhinostomy (DCR) with or without a posterior mucosal flap and to compare the surgical success rates of that procedure in patients with a nasolacrimal duct obstruction. PATIENTS AND METHODS: We retrospectively investigated the results of 78 endoscopic endonasal DCRs performed at the Baskent University, Department of Otolaryngology between December 2000 and March 2007 on 74 patients with a lacrimal obstruction. The patients were divided into two groups. During surgery, the posterior mucosal flap was preserved in 27 patients (group A) and removed in 47 patients (group B). All patients underwent intubation with a silicone tube at the conclusion of surgery. The silicone tube was removed within 6 months after surgery. The mean follow-up period was 36 months (range, 2-78 months). The results obtained were then compared. RESULTS: Granulation tissue and synechia developed between the lateral nasal wall and the middle turbinate in one patient in group A (revision surgery was not required). In group B, granulation tissue at the rhinostomy opening was found in seven patients, and in four of those subjects, the granulation tissue obstructed the neo-ostium. These four patients underwent a second operation. In group B, synechia was noted between the middle turbinate and the lateral nasal wall in two of 47 patients. In group A, the procedure was successful for all patients except one in whom granulation tissue developed, and in group B, the surgical success rate was 88.3%. CONCLUSION: In endoscopic endonasal DCR, the closure of bare bone with a posteriorly based nasal mucosal flap that creates an anastomosis between the lacrimal sac mucosa and the nasal mucosa decreases the formation of granulation tissue. But, there is no significant difference of success rate between two groups.

[A case of herpetic facial paralysis in which cochleovestibular symptoms outweigh facial nerve symptoms]. / Kokleovestibüler semptomlarin ön planda oldugu herpetik fasyal paralizi: Olgu sunumu.

A 42-year-old man presented with sensorineural hearing loss of acute onset, tinnitus, and vertigo. Physical examination revealed slight asymmetry in facial nerve functions and spontaneous nystagmus. Magnetic resonance imaging of the internal acoustic canal showed contrast enhancement consistent with edema-inflammation, being notable and diffuse in the seventh and eighth cranial nerve complex, and minimal in the cochlea. Non-hydropic cochleovestibular syndrome was considered and the patient was treated with antiviral and corticosteroid medications. A week later, facial paralysis improved and the acute hearing loss reversed. On the twelfth day of presentation, he had no complaints other than mild imbalance on abrupt changes in movement. In this type of herpetic facial paralysis in which cochleovestibular symptoms outweigh facial nerve symptoms, it might be argued that varicella zoster virus reactivation occurs in the spiral and/or vestibular ganglion.

[A giant retropharyngeal lipoma showing no change in clinical presentation and size within a two-year follow-up: a case report]. / Iki yillik takipte kliniginde ve boyutunda degisiklik saptanmayan dev retrofarengeal lipom: Olgu sunumu.

Retropharyngeal tumors are rare. They typically originate from the neighboring anatomical structures or from the retropharyngeal space itself. Retropharyngeal lipomas are even rarer. A 75-year-old male patient presented with complaints of dyspnea, dysphagia, snoring, and obstructive sleep apnea. Computed tomography showed a giant mass measuring 125 x 81 x 27 mm in the retropharyngeal space, compressing the larynx, trachea, and esophagus, and extending to the thoracic inlet. The mass had regular margins, exhibited low attenuation, and was homogeneously hypodense. After intravenous contrast administration, there were thin septa formations within the lesion that did not show contrast enhancement. There was no invasion to the neighboring muscular structures. The lesion was considered a lipoma. Surgery was not performed due to the cardiovascular problems of the patient. During a two-year follow-up, there were no changes in the size and tissue characteristics of the mass, nor any mass-related clinical problems.

Case report and surgical solution for nasal spine agenesis in a woman with Binder syndrome.

Binder syndrome is an uncommon disorder of unknown etiology. It is characterized by hypoplasia of the nose and maxilla and altered morphology of the associated soft tissue. We report a 19-year-old Binder syndrome patient with short-nose deformity and anterior nasal spine agenesis. We present a surgical technique for nasal spine agenesis treatment. We used a titanium screw without a graft, which supported the nasal tip and increased tip projection. As there is good soft-tissue coverage over the screw, infection or extrusion was not encountered, and the patient had no complaints 1 year after surgery.

Lingual tonsillar hypertrophy: a case report.

The lingual tonsils, members of Waldeyer's ring, are often overlooked even in a thorough head and neck examination. A 39-year old man with one-year history of globus sensation was admitted to our clinic. In indirect laryngoscopic examination, symmetrical masses of lingual tonsillar tissue were detected, extending posteriorly from base of the tongue that was confirmed by magnetic resonance imaging. The patient refused surgical intervention. Acute inflammation and hypertrophy of lingual tonsil can cause life-threatening airway obstruction. In order to draw attention to this frequently unrecognized entity, we present a review of the literature and our case.