Factors Affecting Optimal Titration Pressure of Continuous Positive Airway Pressure Device in Patients with Obstructive Sleep Apnea Syndrome.

OBJECTIVE: To assess the effects of anatomical, clinical parameters, and pulmonary respiratory function on the therapeutic titration pressure of continuous positive airway pressure (CPAP) device in obstructive sleep apnea syndrome (OSAS). METHODS: The study comprised 41 OSAS patients whose optimum CPAP titration pressures were measured. Each patient underwent an otorhinolaryngologic and thoracic examination, and data was recorded for height, weight, body mass index, neck-waist circumferences, Mallampati classification, tonsillar hypertrophy, hypopharyngeal collapse, soft palate-tongue base obstruction scores, peak nasal inspiratory flow and acoustic rhinometry measures, and CPAP device therapeutic pressures. Forced vital capacity, forced expiratory volume, FEV1/FVC ratio and peak expiratory flow values were noted. RESULTS: Median CPAP optimal pressure cut-off value was determined as 9 mmH2O. Statistical analysis was made in two groups as CPAP titration optimal pressure ≤9 and >9 mmH2O. In the optimal pressure >9 group, neck and waist circumferences, hypopharyngeal collapse score, retropalatal and retrolingual lateral wall collapse scores were significantly higher (p<0.05). In multivariate and univariate model analysis, neck and waist circumferences, hypopharyngeal collapse score, retropalatal and retrolingual lateral wall collapse scores were observed to be significant in predicting high and low pressures in univariate model. CONCLUSION: For the prediction of optimal CPAP titration pressure in OSAS treatment, wide neck and waist circumferences, high hypopharyngeal collapse score and retropalatal and retrolingual lateral wall collapse grades may be determinative.

Does procalcitonin have a role in the pathogenesis of nasal polyp?

PURPOSE: The aim of this study is to investigate serum and tissue procalcitonin (PCT) levels in patients with nasal polyps. METHODS: The study was designed to be prospectively controlled and included 26 patients chronic rhinosinusitis with nasal polyp (CRSwNP) endoscopically diagnosed and as a control group 25 chronic rhinosinusitis without nasal polyp (CRSsNP). NP specimens, nasal mucosal tissue and venous blood samples of both groups were collected and PCT levels determined by Elisa method. The results were compared statistically. RESULTS: Serum PCT values were 1319.5 pg/mL in the NP group and 818.8 pg/mL in the control group. The difference between the groups was statistically significant (p = 0.0001). In the NP group, the average PCT value of the polyp tissue was 1521.5 pg/gr, while the mean PCT value of the control group in the nasal mucosa was 414.6 pg/gr. There was a statistically significant difference between the groups (p = 0.0001). The tissue cut-off value of PCT 750 was significant [area under curve 0.940 (0.863-1.00)]. Serum PCT 950 cut-off value was significant [area under curve 0.860 (0.748-0.972)] activity (CI: 95%). CONCLUSIONS: This is the first study of its kind to objectively examine PCT in the polyp and serum of CRSwNP patients. PCT may serve as a diagnostic biomarker in nasal polyps.

Imaging Modalities in the Etiologic Evaluation of Unilateral Vocal Fold Paralysis.

OBJECTIVE: This study aimed to investigate the roles of computed tomography (CT) and neck ultrasonography (US) in evaluating unilateral vocal fold paralysis (UVFP) of unknown etiology and to compare our results with those of other studies to assess the differences in etiology of UVFP. METHODS: We investigated the medical records of 202 eligible patients with UVFP. In total, 168 underwent chest CT, 118 underwent neck CT, and 108 underwent head CT. One hundred and three patients were also evaluated with high-resolution neck US. The etiologic causes of UVFP were also determined. RESULTS: Of the 202 eligible patients, the occult cause of the UVFP was determined in 96 patients (47.5%). Idiopathic causes were the most common etiologies (n = 106). In occult causes group, chest lesions were the most common diseases causing paralysis (52 cases) and included lung cancer (n = 28) and mediastinal malignancy (n = 8). More than half of the neck lesions were of thyroid origin. Of the 18 thyroid lesions, 12 were thyroid malignancies. Chest CT had an intermediate yield of 30.9% (52 of 168). Neck US had a diagnostic yield close to that of neck CT (26.2%). CONCLUSION: UVFP may result mainly from idiopathic, lung cancer, mediastinal, and thyroid malignancies. The initial use of neck US as an alternative to CT may be advocated for the determination of diseases resulting in UVFP.

Relations Between Hyoid-Related Cephalometric Measurements and Severity of Obstructive Sleep Apnea.

OBJECTIVE: To evaluate the relationship between the hyoid-related cephalometric measurements and the apnea-hypopnea index (AHI) in patients diagnosed with obstructive sleep apnea (OSA). METHODS: A total of 56 subjects were evaluated by lateral cephalometric radiography and polysomnography (PSG). The OSA diagnosis was made according to the patients' AHI. Included were 13 primary snoring, 16 mild OSA, 10 moderate OSA, and 17 severe OSA. C3-hyoid distance and mentum-hyoid distance were measured on lateral cephalogram. Cephalometric measurements and PSG parameters were compared among the different OSA groups. RESULTS: The distance between the mentum and hyoid was significantly longer in the severe OSA group than in the primary snoring, mild OSA, and moderate OSA groups (P = 0.029). There was a significant positive correlation between the AHI value and the distance of the mentum hyoid (r = 0.368, P = 0.005). The C3-hyoid distance among the groups was not statistically significant different (P = 0.889). CONCLUSION: The mentum-hyoid distance of patients with severe OSA was longer compared to the other OSA groups. These patients might have more benefit from the surgeries that have an impact on the position of the hyoid bone compared to other patients with OSA.

Histopathological investigation of intranodular echogenic foci detected by thyroid ultrasonography.

OBJECTIVE: To determine the predictability of sonography for detection of calcifications in thyroid nodules by histopathologic examination and to demonstrate the association between calcification pattern and malignancy. METHODS: We prospectively evaluated 81 dominant nodules from 81 patients. Thyroid glands were assessed preoperatively with thyroid ultrasonography, and the presence of sonographic calcification was specified as intranodular macro (coarse) and micro calcification. Micro and macro calcification in surgery specimens were specified postoperatively as present or absent in the histopathological evaluation. The correlation between sonographic and histopathologic calcifications and the relationship between malignancy and calcification patterns were determined. RESULTS: Calcification was detected histopathologically in 66.7% of the sonographically calcified nodules and in 12.8% of the sonographically noncalcified nodules. The sensitivity and specificity of sonography for detecting histopathologic calcification were 84.8 and 70.8%, respectively, while positive and negative predictive values were 66.7 and 87.2%, respectively. The sonographical and histopathological outcomes for detection of macro and micro calcification showed 85 and 50% compatibility, respectively. The difference in malignancy rates between sonographic macro and micro calcified nodules was not significant (p=0.976). Histopathologic detection of calcification showed no significant difference between malignant and benign nodules (p=0.129). CONCLUSION: Histopathology confirmed a high rate of sonographic macrocalcifications. The micro and macro patterns of sonographic calcification showed no particular association with thyroid malignancy. The preoperative risk of malignancy should be determined in conjunction with other known sonographic risk factors and diagnostic tests.

Short-term Effects of Radioiodine Therapy on Auditory Function.

OBJECTIVE: Radioiodine therapy (RIT) is frequently utilized as an adjunctive treatment option for differentiated thyroid carcinoma following surgical intervention. The side effects of RIT are considered to emerge as a result of radioiodine accumulation in non-thyroidal tissues capable of iodine uptake. We aimed to evaluate the effects of RIT on auditory function. MATERIALS AND METHODS: Patients who had undergone total thyroidectomy and diagnosed to have differentiated thyroid carcinoma were analyzed. Those who were given RIT were included. Pure-tone audiometry and distortion product otoacoustic emission (DP-OAE) results were recorded along with patient demographics, RIT dose, and thyroid hormone profiles, both before and 3 months after RIT. RESULTS: Here, 63 patients were enrolled. Following RIT, audiometric thresholds at 0.25, 0.5, 4, and 8 kHz in addition to pure-tone average increased significantly; however, the change in DP-OAE results was not statistically significant at any frequency. The RIT dose had no effect on auditory function. CONCLUSION: In this study, we found some deleterious effects of RIT on audiometric thresholds, with no significant effect on DP-OAE results.

Submental Ultrasonographic Parameters among Patients with Obstructive Sleep Apnea.

Objective This study aimed to determine the value of submental ultrasonography (US) parameters for diagnostic workup among patients with obstructive sleep apnea (OSA) and to determine whether there is a correlation between US findings and the severity of OSA. Study Design Cross-sectional analysis. Setting Tertiary education hospital. Subjects and Methods The study included 147 patients with suspected OSA who underwent submental US to evaluate various parameters following overnight polysomnography. US findings were compared with the apnea-hypopnea index and other parameters. Results All US parameters, except for subcutaneous tissue thickness, were significantly different among patients with OSA. Of note, distance between lingual arteries (DLA), geniohyoid muscle thickness (GMT), and lateral parapharyngeal wall thickness (LPWT) were significantly greater in the patients with severe OSA than those with mild and moderate OSA ( P < .001). GMT had the strongest correlation with OSA ( r = 0.419, P < .001); LPWT and DLA also had high correlation coefficient values ( r = 0.343, P < .001, and r = 0.342, P < .001, respectively). Stepwise regression analysis showed that GMT (beta = 0.243, P = 0.004), LPWT (beta = 0.236, P = 0.004), and DLA (beta = 0.204, P = 0.008) were the most significant factors for predicting the severity of OSA according to the apnea-hypopnea index. Conclusion Submental US can be used to determine whether there is a correlation between US findings and severity of OSA. GMT could be considered a novel parameter for determining the severity of OSA.

Ceruminous Adenocarcinoma of External Auditory Canal: A Case Report.

The external auditory canal contains ceruminous glands, which are modified apocrine sweat glands, along with sebaceous glands. Tumors that originate from ceruminous glands are very rare; thus, the classification, clinical behavior, and management of these tumors remain debatable. Here we present a case of ceruminous adenocarcinoma arising from the external auditory canal. Although most authors advise more aggressive therapy, our patient was treated with local en bloc resection of the tumor followed by intensity modulated radiotherapy and had no recurrence for 3 years. We suggest that limited surgery with safe margins followed by radiotherapy is an alternative choice of treatment in selected patients with ceruminous adenocarcinoma. Further reports are required to support this outcome.

The effect of mupirocin- and fusidic acid-nasal packings, placed after septoplasty, on the nasal bacterial profile.

AIM: To examine the effects, after septoplasty, of local antibiotic pomades as an alternative to prophylactic antibiotic use, which is a controversial matter among the otolaryngologists, on nasal flora and bacterial growth. MATERIAL AND METHOD: Nasal packings placed after septoplasty surgery to provide septal stabilization and bleeding control pose a risk in terms of infection. In this study, 106 patients, who were examined by comparing mupirocin- and fusidic acid-soaked packings and antibiotic-free packings, were divided into three groups. Nasal cultures were obtained from each patient twice, before the surgery and on the second day immediately after the packings were removed, and the culture results were statistically compared. RESULTS: In the mupirocin group (group 2), postoperative normal flora growth rate was significantly higher than in the fusidic acid group (group 3) and the antibiotic-free group (group 1) (p < 0.024). In the mupirocin group (group 2), the gram-positive growth rate in the postoperative period showed a significant decrease when compared when the preoperative period (p < 0.05) (5.7%). In the fusidic acid group (group 3), the postoperative gram-positive rate showed a significant decrease compared with the preoperative period (p < 0.05). In group 2, the postoperative methicillin-resistant Staphylococcus aureus rate showed a significant decrease than in the preoperative period (2.9%) (p < 0.05). Similarly, in group 3, the postoperative methicillin-resistant S. aureus rate showed a significant decrease compared with that of the preoperative period (11.1%) (p < 0.05). CONCLUSION: Use of mupirocin- and fusidic acid-soaked nasal packings after septoplasty significantly decreased, especially, postoperative gram-positive bacterial growth in nasal cultures. Although systemic antibiotherapy was not administered, the lack of local and systemic infection findings was an important result that we obtained in terms of clinical use. Usage advantages of mupirocin and fusidic acid soaked packings are an easily applicable, cost-effective, and safe method.

The changes in histopathology and mass in hyperbaric oxygen-treated auricular cartilage grafts in a rabbit model.

The aim of the study is to investigate the histopathologic and cartilage mass changes in hyperbaric oxygen (HBO)-treated auricular cartilage grafts either crushed or fascia wrapped in a rabbit model. This is a prospective, controlled experimental study. Sixteen rabbits were randomly allocated into control (n = 8) and treatment groups (n = 8). Each group was further grouped as crushed cartilage (n = 4) and fascia wrapped crushed cartilage (n = 4). The eight rabbits in the treatment group had HBO once daily for 10 days as total of 10 sessions. The mass of cartilage, cartilage edge layout, structural layout, staining disorders of the chondroid matrix, necrosis, calcification besides bone metaplasia, chronic inflammation in the surrounding tissues, fibrosis, and increased vascularity were evaluated in the hematoxylin and eosin (H&E)-stained sections. Fibrosis in the surrounding tissue and cartilage matrix was evaluated with Masson's trichrome stain. The toluidine blue staining was used to evaluate loss of metachromasia in matrix. The prevalence of glial fibrillary acidic protein (GFAP) staining in chondrocytes was also evaluated. Although the remaining amount of cartilage mass after implantation does not show a significant difference between the control and the study group (p = 0.322, p <0.05).The difference between control and study group in terms of positive staining with GFAP was statistically significant (p = 0.01, p <0.05). Necrosis and loss of matrix metachromasia were significantly low in the study group compared with control group (p = 0.001, p = 0.006, p <0.05). HBO therapy did not have significant effect on the mass of rabbit auricular cartilage graft. HBO therapy significantly reduced loss of metachromasia, necrosis, and GFAP staining in the auricular cartilage grafts of the animal model.

Medium-term results of combined treatment with transcranial magnetic stimulation and antidepressant drug for chronic tinnitus.

We compared the effects of repetitive transcranial magnetic stimulation (rTMS) and paroxetine [a selective serotonin reuptake inhibitor (SSRI)] on tinnitus in terms of effectiveness and medium-term results. This is a randomised, double-blind, placebo-controlled study. Seventy-five patients with moderate tinnitus were divided into five equal groups. Each group was treated for 1 month as follows: group 1 received rTMS alone at 1 Hz frequency; group 2 received rTMS alone at 10 Hz frequency; group 3 received rTMS at 1 Hz frequency combined with paroxetine; group 4 received paroxetine alone; and group 5 received a placebo (sham rTMS). Participants were tested using the Tinnitus Handicap Inventory (THI), Tinnitus Severity Index (TSI), the Beck Anxiety Scoring (BAS), and Psychiatric Sign Screening (PSS) tests. THI, TSI, BAS, and PSS were measured prior to treatment, and at the first and sixth month post-treatment. The THI and TSI scores improved after treatment in all groups, except the placebo group. The THI scores in groups 1 and 2 showed a statistically significant improvement after the first and sixth month compared to pretreatment scores, whereas a significant improvement in THI scores occurred only after the sixth month in groups 3 and 4. The TSI scores in group 3 showed a significant improvement at the first and sixth month marks after treatment. The rTMS and SSRI play potential roles in the reduction of tinnitus severity, but without cumulative or synergistic effects when a combination of treatment regimens is applied. These positive effects might be due to the relationship between the auditory cortex areas related to emotions and tinnitus.

Giant arteriovenous malformation of the floor of the mouth presenting with dysarthria and difficulty in swallowing.

Arteriovenous malformation (AVM) is a vascular abnormality resulting in the development of abnormal connection between an artery and vein without capillary connections. An AVM develops mainly intracranially. Extracranial AVMs are rarely seen. Cheek, ear, nose, auricle, and forehead are the more common sites in the extracranial involvement. They cause cosmetic problems when located in the head and neck region. We report a case of a giant AVM in the floor of the mouth, which has not been specified and has not been reported until now. The lesion, in an elderly man, was supplied by multiple vessels and caused difficulty in speaking and swallowing. The lesion was totally excised after embolization of feeding vessels.

Recurrence of a simultaneous tumor of the parotid gland and scalp skin malignant fibrous histiocytoma.

Malignant fibrous histiocytoma (MFH) is one of the most common soft-tissue sarcomas and generally arises in elderly patients. Most often, MFH occurs in the extremities and the retroperitoneum; MFH of the head and neck region is only reported in 3% of all cases. The distant metastasis appears in one third of all cases, and those cases mainly involve the lung, regional lymph nodes, the liver, or bones. The main treatment of MFH of the head and neck is radical excision of the tumor with modified or radical neck dissection. Recurrences of MFH are commonly seen and identified within the first 2 years of treatment. We report a case of simultaneous MFH tumors of the parotid gland and of the scalp skin in an elderly male patient. The patient underwent a wide surgical excision of the lesion and referred to the oncology department for further treatment. However, 1 month after chemoradiotherapy had commenced, there was a recurrence of the tumor over the skin on the right parotid region.

Ancient schwannoma of the tongue: a case report.

A 45-year-old male patient had left sided submucosal swelling extending backwards from the tip of the tongue disturbing articulation and swallowing. Submucosally located lesion was 3 x 2 x 1.5 cm in size and totally excised under local anesthesia. In this article, we present a case of ancient schwannoma of tongue. Although a very rare entity, ancient schwannoma should be considered in differential diagnosis of tongue lesions.

Efficacy of the combination of intraoperative cold saline-soaked gauze compression and corticosteroids on rhinoplasty morbidity.

OBJECTIVE: The basic aim of this study was to minimize intraoperative bleeding, postoperative eyelid edema, and periorbital ecchymosis and to reduce morbidity with a combination of cold saline-soaked gauze compression and intraoperative single-dose corticosteroids. STUDY DESIGN: The study was designed as a prospective, double-blind, randomized controlled study. Three hundred patients who underwent septorhinoplasty were included. SETTING: A tertiary referral hospital in Turkey. SUBJECTS AND METHODS: Three hundred patients undergoing septorhinoplasty were divided into 2 groups. A single dose of 10 mg dexamethasone was intravenously administered in all cases at the beginning of the operation. In the study group, the nasal dorsum was continuously compressed with cold saline-soaked gauze during the operation. In the control group, the nasal dorsum was compressed with dry gauze continuously during surgery. The operation time and amount of bleeding were recorded during surgery. Degree of eyelid edema and periorbital soft tissue ecchymosis was recorded at 24 hours and on postoperative days 2, 3, 5, and 7 by 2 investigators. RESULTS: The operation time was significantly shorter in the study group than in the control group. Eyelid edema and periorbital ecchymosis were significantly decreased in the study group at the following postoperative days 1, 3, 5, and 7 (P < .05). CONCLUSION: Bleeding, edema, and ecchymosis are the main morbidities of rhinoplasty. It is highly probable that cold compression and intraoperative corticosteroids have synergistic effects on these morbidities, especially by the intraoperative control of bleeding.