Modified Anterolateral Minimally Invasive Surgery (ALMIS) for Total Hip Replacement: Anatomical Considerations, Range of Motion and Clinical Outcomes.

Background and Objectives: In the modified anterolateral minimally invasive surgery (ALMIS) for total hip arthroplasty (THA), the intermuscular plane between the tensor fasciae latae and the gluteus maximus (GM) is exposed, while the anterior » of the GM is detached. There are scarce data regarding this surgical approach. The purpose of the present study is to thoroughly describe this approach, encompassing the anatomical background, and to present the results of a retrospective two-center study of 603 patients. Materials and Methods: The present study includes a two-center retrospective observational cohort of 603 patients undergoing the ALMIS technique with minimum 5-year follow-up. Demographics were recorded, while range of motion (ROM) of the hip joint and the Harris Hip Score (HHS) were evaluated preoperatively, at 1, 3 and 12 months postoperatively and at the final follow-up (>5 years). Surgery-related complications were also recorded. Results: The studied population's mean age was 69.4 years, while most of them were females (397; 65.8%). The mean follow-up was 6.9 years. The median HHS at the 1-month follow-up was 74, compared to the 47 preoperatively (p-value < 0.0001). At the final follow-up, median HHS was 94. At the 1-month follow-up, mean adduction was 19.9° (compared to 15.4° preoperatively; p < 0.0001), mean abduction 24.3° (18.2° preoperatively; p < 0.0001), mean flexion 107.8° (79.1° preoperatively; p < 0.0001), mean external rotation 20.1° (12.1° preoperatively; p < 0.0001) and mean internal rotation 15.3° (7.2° preoperatively; p < 0.0001). ROM further improved until the final follow-up; mean adduction reached 22°, mean abduction 27.1°, mean flexion 119.8°, mean external rotation 24.4° and mean internal rotation 19.7°. Regarding complications, 1.3% of the sample suffered anterior traumatic dislocation, in 1.8% an intraoperative femoral fracture occurred, while 1.2% suffered periprosthetic joint infection. Conclusions: The modified ALMIS technique exhibited excellent clinical outcomes at short-, mid- and long-term follow-up, by significantly improving hip ROM and the HHS. Careful utilization of this technique, after adequate training, should yield favorable outcomes, while minimal major complications should be expected.

Hamartomatous polyp of the palatine tonsil: histological considerations and review of the literature.

The hamartomatous polyp is a rare benign hamartoma of the palatine tonsil, usually encountered during the second decade of life. It may be reported under various terms in the literature, like lymphangioma of the tonsil, angiofibrolipoma, lymphangiomatous tonsillar polyp and lymphangiectatic fibrous polyp. Macroscopically, it appears as a large, pale, pedunculated mass. Typically, a hamartomatous polyp is asymptomatic or manifests mild symptoms, like foreign body sensation. It is not related to a generalised lymphatic malformation process. Despite its typical appearance, an excisional biopsy is necessary to rule out a malignancy. Histological findings are consistent with a squamous epithelial covering, a core of loose fibrous and adipose tissue with sparse lymphoid aggregations and dilated lymphatic channels filled with lymph and lymphocytes. Several embryologically based theories suggested its pathogenesis; however, recurrent tonsillitis does not play an established role. A typical tonsillectomy is suggested as a sufficient therapeutical approach with no tendency for recurrence.

Pathogenesis of Nasal Polyposis: Current Trends.

Chronic Rhinosinusitis (CRS) is characterized by edema of the sub-epithelial layers, but, only specific types of CRS are developing polyps. Nasal polyposis may develop under different pathogenetic mechanisms rendering the typical macroscopic classification of CRS, with or without nasal polyps, rather deficient. Currently, we approach nasal polyposis, in terms of diagnosis and treatment, according to its endotype, which means that we focus on the specific cells and cytokines that are participating in its pathogenesis. It appears that the molecular procedures that contribute to polyp formation, initiating with a Th-2 response of the adaptive immune system, are local phenomena occurring in the sub-epithelial layers of the mucosa. Several hypotheses are trying to approach the etiology that drives the immune response towards Th-2 type. Extrinsic factors, like fungi, Staphylococcus superantigens, biofilms, and altered microbiome can contribute to a modified and intense local reaction of the immune system. Some hypotheses based on intrinsic factors like the elimination of Treg lymphocytes, low local vitamin-D levels, high levels of leukotrienes, epithelial to mesenchymal transition (EMT) induced by hypoxia, and altered levels of NO, add pieces to the puzzle of the pathogenesis of nasal polyposis. Currently, the most complete theory is that of epithelial immune barrier dysfunction. Intrinsic and extrinsic conditions can damage the epithelial barrier rendering sub-epithelial layers more vulnerable to invasion by pathogens that trigger a Th-2 response of the adaptive immune system. Th2 cytokines, subsequently, induce the accumulation of eosinophils and IgE together with the remodeling of the stroma in the sub-epithelial layers leading, eventually, to the formation of nasal polyps.

Novel Indices to Improve the Diagnostic Ability of Nocturnal Oximetry in Children with OSAS.

Nocturnal pulse oximetry (NOx) is an alternative diagnostic test for obstructive sleep apnea syndrome (OSAS) in childhood yet with variable diagnostic performance. Our aim was to apply advanced signal analysis to develop novel and more accurate NOx indices. We studied 45 children aged 3-10 years who underwent adenotonsillectomy for adenotonsillar hypertrophy and OSAS symptoms. Participants performed NOx before and three months after surgery, and the changes in McGill oximetry score (MOS), oxygen desaturation ≥3% index (ODI3), and the novel parameters-cumulative saturation area (CSA) and oxygen saturation sample entropy (SSE)-were assessed. There was a significant improvement (p < 0.001) in all NOx indices. When pre- and post-adenotonsillectomy NOx recordings were compared, the MOS had an area under the curve (AUC) of 0.811 with 63.2% sensitivity and 100% specificity at a cutoff >1. The AUC of ODI3 was 0.994, with 97.8% sensitivity and 91.1% specificity at a cutoff of >3.6 events per hour. The CSA and SSE had an AUC of 1.00, with 100% sensitivity and specificity at a cutoff of >293 and >0.99, respectively. We conclude that the herein-introduced indices-CSA and SSE-hold promise in improving the diagnostic ability of NOx in children suspected of OSAS.

Hearing screening test in neonates born to COVID-19-positive mothers.

SARS-CoV-2, the responsible virus for the COVID-19 pandemic, has demonstrated neurotropic properties indicated by cases presenting with auditory and vestibular system insults. The expression of ACE-2 receptors in the placenta and the detection of IgM antibodies against the virus in the fetuses of pregnant women suffering from COVID-19 render vertical transmission of the infection to the fetus possible. Thus, our study aims to examine whether, similar to other viruses like CMV, SARS-CoV-2 is responsible for congenital hearing loss. This is a retrospective study in a regional pediatric hospital. The medical records of newborns (n = 111) born by mothers positive for COVID-19 during pregnancy who underwent screening hearing tests with Transient Evoked Otoacoustic Emissions (TEOAE) and Automatic Auditory Brainstem Response (AABR) from February 2020 to June 2022 were reviewed. Neonates with additional aggravating factors for congenital hearing loss were excluded from the study. For the study period, nine mothers were found positive during the first trimester, twenty mothers in the second trimester, and eighty-three mothers in the third trimester. TEOAEs test and AABR test scored PASS bilaterally in all neonates tested. CONCLUSION: Infection with COVID-19 during pregnancy was not a risk factor for hearing loss, similar to other studies. WHAT IS KNOWN: • The pathogenetic mechanism of the viral-induced impairment of the organ of Corti includes direct damage to the hair cells and indirect damage due to the induction of the innate inflammatory response. • Early data suggested that the SARS-CoV-2 virus also has neurotropic properties with manifestations from the sensory epithelia. WHAT IS NEW: • Although the intrauterine infection remains controversial, the expression of the ACE-2 receptor on the placenta and the detection of IgM antibodies, as well as the covid-19 genome in fetuses, make the vertical transmission tenable. • In our study, the newborn hearing screening results indicate that COVID-19 infection during pregnancy is not a risk factor for hearing loss.

Multiple Wasp Stings on a Child's Supraglottis.

Hymenoptera stings are notorious for producing severe anaphylaxis; localized effects (edema, erythema) are far more common, especially in children. However, even an innocent focused lesion may be life-threatening when the sting is directed to the airway. We present the case of a child enduring consecutive wasp stings on the supraglottis.

Surgery for adenotonsillar hypertrophy and otitis media in children is less demanded in quarantine times.

OBJECTIVES: In the COVID-19 era, extreme measures of social distancing have contained the spread of common viral respiratory infections, which are involved in the pathogenesis of Adenotonsillar Hypertrophy (ATH), and Chronic Otitis Media with Effusion (COME), the two commonest chronic ENT diseases of childhood. This study examines the lockdown effect on the number of procedures performed for these two conditions. METHODS: The consecutive charts of 650 and 195 children being operated respectively for ATH and COME during the quarantine (05/2020-02/2021) and unrestrained (05/2019-02/2020) periods were retrospectively reviewed. Surgical treatment of ankyloglossia, performed in 103 patients during the same periods was employed as a control procedure. RESULTS: Adenotonsillectomies and tympanostomies significantly decreased in the lockdown phase by 52% (P < 0.001) and 74% (P < 0.001), respectively, whereas control procedure counts increased by 25%. In terms of seasonal variation, ATH-related surgeries were significantly reduced during the winter season of the pandemic by 73% (P < 0.001), in comparison with the corresponding months of the unrestrained period. School-aged children received significantly fewer operations for ATH (-59%) than preschoolers (-42%), as a result of the lockdown (P = 0.044). CONCLUSION: When the child's exposure to respiratory pathogens is minimal, as in the case of lockdown, a noticeable decline occurs in the incidence of ATH and COME indicated for surgical treatment. Chronic low-grade inflammation, boosted by repetitive viral infections seems to underlie both conditions. Timely, effective isolation measures might reverse the disease process and keep the child away from the Operating Room.

Haematologic Markers and Tonsil-to-Body Weight Ratio to Assist Adenotonsillar Hypertrophy Diagnosis.

Aims Diagnosis of Adenotonsillar Hypertrophy (ATH), the leading cause of pediatric Obstructive Sleep Apnea (OSA), depends on physical exam via Brodsky's staging of tonsils. This study investigates the associations of ATH with patient parameters, and balances in-office tonsil hypertrophy appraisal against true organ mass. Materials and Methods A prospective cohort was formed of 103 children operated for ATH, and 31 matched controls. Demographic, clinical and tympanographic data, as well as Complete Blood Count (CBC) indices were compared. Absolute and relative to total body weight tonsil specimen mass were correlated with Brodsky's score. Results Tonsillar size indices were significantly raised in ATH patients. Elevated leukocytes (P = 0.012) and increased neutrophil percentage (P = 0.025) conveyed higher ATH risk. Subjective evaluation of tonsils graded 1 or 2 correlated significantly with absolute (P = 0.001) and relative (P = 0.006) objective measurements. Brodsky's score 3 and 4 displayed marginal significant association with relative (P = 0.050) but not with true (P = 0.989) mass. Conclusion An occult hematologic inflammatory response was detected in ATH children. Clinical estimation of severely hypertrophic tonsils should be adjusted for total body weight. Trial Registration Number: NCT03541434 (clinicaltrials.gov).

Anterolateral Minimally Invasive Total Hip Arthroplasty: Pitfalls During the Learning Curve and Clinical Outcomes.

Introduction:To report outcomes and complications from a modified anterolateral minimal invasive surgery (ALMIS) approach for total hip arthroplasty (THA). Patients and methods: All patients undergoing THA through ALMIS approach during a seven-year period were retrospectively evaluated. Results:One hundred fifty-four patients with a mean follow-up of 4.6 years were studied. The mean Harris hip score was found to be 91.1. A number of complications were recorded, including two cases (1.3%) of greater avulsion trochanter, one case (0.6%) of femur fractures, 12 (7.8%) cases of Trendelenburg sign and 12 cases of heterotopic ossification. Conclusions: This approach offers good visualization during acetabulum and femur preparation and excellent clinical results during mid-term follow-up.

Rising Resonance Frequency Is the Sole Sign of Early Middle Ear Disease in Children With Adenoid Hypertrophy.

OBJECTIVE: The present study seeks to estimate the potential of multifrequency tympanometry in the diagnosis of primal otologic disorder in children with adenoid hypertrophy (AH). STUDY DESIGN: Prospective observational study. SETTING: Tertiary pediatric institution. PATIENTS: One hundred thirty-one children presenting consecutively at the otolaryngology clinic were divided on the basis of AH into 98 patients and 33 controls. INTERVENTIONS: Middle ear status was assessed using pneumatic otoscopy, standard, and wide band tympanometry. MAIN OUTCOME MEASURES: Tympanogram type/intratympanic pressure, and resonance frequency (RF) were correlated with each other as well as with a set of clinical parameters. Receiver operating characteristic analysis was employed to reveal the diagnostic value of RF. RESULTS: Mean RF declined in chronic otitis media with effusion by 43.25% (p < 0.001). In our entire cohort, children with AH under the age of 7 years presented with a relative risk = 2.43 of producing "B" tympanogram (p = 0.016) than their older peers. In patients' ears with normal, type "A," tympanogram, RF was the sole tympanometric marker of AH, being elevated by 28.26% in mean value (p = 0.010). On receiver operating characteristic analysis of RF's discriminating capability, the area under the curve was equal to 0.647 (p = 0.010). The optimal cut-off value of RF was set at 899 Hz. CONCLUSION: AH may induce middle ear stiffening, as RF's increase indicates. Wide band tympanometry output could be a warning sign of ongoing compliance reduction to the sound transmission apparatus, at a time point when physical examination and 226 Hz tympanometry are still unremarkable.

The Effect of Quarantine Due to COVID-19 Pandemic in Surgically Treated Fractures in Greece: a Two-Center Study.

Objectives: Many countries have implemented quarantines to control the Coronavirus (COVID-19) pandemic spread. The quarantine effects on surgically-treated fractures, operated during this period (March 9th - May 4th) in two public Greek institutions, the "Venizeleion" General Hospital of Crete (VGH) and the "251" Hellenic Air Force General Hospital of Athens ("251" HAFGH) were evaluated and compared with those of the same period of 2019. Materials and methods: This is a retrospective study of a prospectively collected database. Evaluated data included gender, age, and trauma mechanism. Outcomes: A total of 103 patients who had suffered fractures were surgically treated in both institutions during the quarantine period of 2020 compared to 179 during the same period of 2019, showing a reduction of 43% in surgical cases. The mean age of patients treated in 2020 was 72.2 (SD=19.9), as compared to 65.3 (SD=21.5; p-value=0.008) in 2019. There were 70 (68%) elderly patients (>65 years) in 2020 and 103 (57.6%) in 2019. Of all treated fractures, 31% were caused by high energy mechanisms during the explored period of 2020, as compared to 45% in 2019 (p-value=0.019). Conclusions: This is the first study in Europe evaluating the effect of COVID-19 quarantine on surgically treated fractures. The findings showed a significant decline in surgically treated fractures, particularly high-energy fractures, along with a significantly higher mean age of patients in 2020 compared to 2019. Low-energy fractures in elderly during quarantine emphasizes the need of prevention measures to minimize their incidence, especially in a time when the health personnel and resources are engaged in the battle against COVID-19.

Ultrasound-guided removal of impalpable, radiolucent vegetative foreign bodies embedded into facial soft tissues of a toddler.

Otolaryngologists frequently encounter children with foreign bodies retained inside the lumen of their upper aerodigestive tract. However, total capture in the soft tissues happens rarely, and could be clinically, as well as radiographically, silent. Ultrasonography is a safe and effective imaging modality, aiding both diagnosis and surgical treatment. We report on a 14-month girl with chronic, fluctuating cheek edema and erythema, induced by an impalpable, radiolucent bundle of organic fibers embedded intramuscularly. Foreign body identification and atraumatic removal were facilitated by real-time ultrasound scanning.

Patents and Recent Innovations in Topical Membrane Therapy of Refractory Rhinosinusitis.

Chronic Rhinosinusitis (CRS), one of the commonest chronic inflammatory disorders, is encountered daily in all healthcare settings. In its refractory form, CRS seems to prevail over most up-to-date surgical interventions and systemic medical remedies, owing to our poor understanding of its perplexing pathophysiology. Although several systemic influences impinge on the progression of inflammation, the true interplay between offensive and defensive factors takes place on-site, i.e. across the sinonasal epithelial coating. Therefore, current treatment strategies shift the weight of CRS management toward topical modalities, which combine the benefits of surgical approach with the healing effect of conventional medications. An explosive emergence of relevant patents is still in progress, emphasizing the need for classification and comparison. Novel delivery methods of medications into the sinus cavities include modifications of traditional rinses, state-of-the-art nebulizing devices, and the revolutionary concept of sustained drug application utilizing carrier gels or nasal implants. As far as the introduction of new medications is concerned, recent patents propose alterations to the physical and chemical properties of irrigating solutions, as well as the local use of antiseptics, hydragogues, and anti-biofilm agents. This review focuses on the local pathophysiologic events of CRS and the most exciting innovations regarding its topical management.

Atypical post-adenoidectomy Grisel's syndrome in Crouzon child with kyphotic skull base.

Crouzon syndrome is characterized by abnormal craniofacial growth due to craniosynostosis. Skull base may also be involved in the pattern of malformations. Grisel's syndrome, an inflammation-mediated atlanto-axial instability occurs rarely in children after adenoidectomy. We report a 9-year-old female Crouzon patient, without vertebral anomalies, who developed severe torticollis few days after adenoid curettage. A deformity of the skull base alone might have induced an irregular arrangement of the craniocervical junction elements, thus increasing the susceptibility to cervical spine complications.

Topical gel therapy for sinonasal polyposis in Samter's triad: preliminary report.

OBJECTIVES: Rhinosinusitis and polyposis are difficult to treat in patients with Samter's triad; they commonly recur despite sinus surgery, antibiotics, and/or nasal steroids. The present study assesses the efficacy of a multimodal regimen that includes topical corticosteroids and antibiotics delivered through a hydroxyethyl cellulose gel and by nebulization. METHODS: Eleven patients with Samter's triad who had polyposis and rhinosinusitis that recurred despite endoscopic sinus surgery were treated with a 6-week course of multimodal topical therapy consisting of a hydroxyethyl cellulose gel that releases corticosteroids and antibiotics, topical nebulization of corticosteroids and antibiotics, saline solution rinses, and sinus debridement. Clinical outcomes were evaluated by Lund-Kennedy endoscopic and symptom scores. Histologic assessment was evaluated by hematoxylin and eosin staining before and after treatment. RESULTS: Both Lund-Kennedy symptom and endoscopic scores showed.a progressive and statistically significant decline throughout the course of treatment, reaching at 6 weeks 42% of the pretreatment values (p = 0.005) for the Lund-Kennedy symptom score and 34% (p = 0.002) for the endoscopic score, respectively; however, the significance of the improvement was lost with time. CONCLUSIONS: Topical gel therapy improves clinical symptoms, endoscopic findings, and sinus membrane histologic features in patients with refractory Samter's triad, but the improvement is transient, suggesting that a longer therapeutic period might be needed.

Low COX2 in tumor and upregulation in stroma mark laryngeal squamous cell carcinoma progression.

OBJECTIVES/HYPOTHESIS: Invasive squamous cell carcinomas (SCC) of the larynx, like most solid tumors, are surrounded by a reactive stroma, in which cancer associated fibroblasts (CAFs) are the predominant cell type. This mesenchymal reaction may affect cancer progression multiply. The proinflammatory enzyme cyclooxygenase-2 (COX-2) has been correlated with head and neck cancer. This study aims to explore the impact of epithelial and stromal COX-2 expression on SCC behavior. STUDY DESIGN: Retrospective case review study performed in a tertiary health center institution. METHODS: Double immunohistochemistry of COX-2 and the CAF marker alpha-smooth muscle actin (alpha-SMA) was utilized in 97 laryngeal cancer patients. Follow-up data were collected in 52 cases. RESULTS: Low COX-2 immunostaining in cancer cells was associated with advanced grade (P = .044) and shorter recurrence-free period (P = .035). CAF expression was positively correlated with the grade of the infiltrating tumor (P = .030). CONCLUSIONS: In laryngeal SCCs, COX-2 may exert its deleterious effect by alterations in the tumor microenvironment. CAF-derived, COX-2-mediated paracrine influences on malignant cells possibly facilitate cancer progression. Overlooking the stromal remodeling could account for unsuccessful treatments of epithelial neoplasms.

Retinoid X receptor overexpression desensitizes laryngeal epithelium to carcinogenic effects associated with epidermal growth factor receptor upregulation.

OBJECTIVE: Squamous cell carcinomas (SCCs) of the larynx are sequelae of hyperplastic and dysplastic lesions. Epidermal growth factor receptor (EGFR) is found frequently overexpressed in SCCs of the head and neck, although its regulatory role is not fully elucidated. Conversely, retinoid X receptor alpha (RXRalpha) mediates the reversing effects of retinoids on head and neck carcinogenesis. We examined the expression of EGFR in relation to the progress of laryngeal tumorigenesis and how this association is modulated by concurrent RXR presence. DESIGN: A retrospective study. SETTING: A basic research anatomy laboratory, operating within a tertiary care institution. MATERIALS: Tissue samples from 129 patients with premalignant or malignant laryngeal lesions. METHOD: Paraffin-section immunohistochemistry. MAIN OUTCOME MEASURES: EGFR immunoreactivity in relation to histopathology progression, in both the presence and absence of RXR immunoexpression. RESULTS: EGFR was upregulated along the epithelial deterioration toward neoplasia (p < .001) but was unaffected by tumour grade. In RXRalpha-positive cases, a markedly stronger induction of EGFR occurred with malignant transformation compared with the epithelia immunonegative for the nuclear receptor. CONCLUSION: This study suggests that RXRalpha confers to squamous cells a shielding effect against excessive mitogenic stimulation, which might be EGFR dependent. RXR-positive patients manifesting resistance to anti-EGFR agents could benefit from rexinoid administration.

Oculoauriculovertebral complex with an atypical cause of obstructive sleep apnea.

Oculoauriculovertebral spectrum (OAVS) is a birth defect of unknown etiology, often causing obstructive sleep apnea, due to unilateral retrognathia. We describe an adolescent sleep apnea patient, with usual and unusual signs of OAVS. Apart from mandibular hypoplasia, microtia, external auditory canal atresia and cervical vertebrae anomalies, skull base asymmetry was also noted, resulting in aberrant anatomy of the tympanic cavity, and nasopharyngeal obstruction, which was the main source of the patient's apneas. The extended craniofacial abnormalities manifested here, suggest a broader developmental impairment, exceeding the 1st and 2nd branchial arch malformation theory, which is the principal hypothesis for OAVS etiology.