Parents' versus Grandparents' Attitudes about Childhood Vaccination.

BACKGROUND: We investigated and compared practices and attitudes about childhood vaccination between young parents and their parents and identified influences and sources of information in the County of Zadar, Croatia. METHODS: This research was conducted in six general practice and paediatric medical clinics. It included 300 volunteers, including 150 younger parents and 150 older grandparents. Information was collected with a survey questionnaire. The survey data were statistically processed. RESULTS: The 300 participants were divided into 2 groups. Most of the respondents were married, employed, had a high school education, and had a good economic status, often with two children and living in the city. Generally, the attitude towards vaccination was positive. Healthcare workers made the most important influence on the decision for vaccination. The younger age group was significantly affected by social networks and the internet and wanted more information. They were afraid of the adjuvants in vaccines. The older respondents held that vaccination must be legally regulated and did not believe the anti-vaccine media headlines. CONCLUSIONS: Our respondents had positive attitudes towards childhood vaccination, noticed the benefits of vaccinating children, and held that untreated children represent a risk for the community. They were well informed and satisfied with the collaboration with medical professionals, although the media and social networks had some impact on attitudes.

Patho-Anatomic Spectrum of Branchial Cleft Anomalies: Proposal of Novel Classification System.

PURPOSE: Histogenesis, nomenclature, and classification of branchial cleft anomalies (BCAs) have been subjects of controversy for decades. The purpose of this study was to investigate the accuracy of current developmental theories (congenital, lymph node, and hybrid branchial inclusion theories) in defining the anatomic and histopathological characteristics of BCAs. METHODS: Ninety consecutive patients with BCAs who underwent surgical excision were enrolled in this 2-center retrospective cohort study. RESULTS: The present study included 90 patients: 46 (51.11%) women and 44 (48.89%) men (P > .05). The mean age at presentation was 31.89±17.31 years. Altogether, 92 BCAs were identified within the study population including 49 (53.26%) on the left side and 43 (46.74%) on the right side (P > .05). The BCAs included 79 (85.87%) branchial cleft cysts, 11 (11.96%) branchial cleft sinuses, and 2 (2.17%) branchial cleft fistulae. Three (3.26%) BCAs were distributed in the head regions, 88 (95.65%) in the neck regions, and 1 (1.09%) in the thoracic cavity. Following surgery, lymphoepithelial tissue was detected in the histopathological examination in 83 (90.22%) BCAs. The hybrid branchial inclusion theory exhibited significantly higher accuracy in defining patho-anatomic characteristics of BCAs than the branchial apparatus, precervical sinus, thymopharyngeal, and inclusion theories (90.22, 9.78, 2.17, 0.00, and 0.00%; respectively) (P < .05). CONCLUSION: The novel branchial node (BN) classification system based on the hybrid branchial inclusion theory appears to be superior to other classification systems in determining the patho-anatomy of BCAs.

Branchial cleft anomalies: hybrid "Branchial Inclusion" theory.

PURPOSE: Branchial cleft anomalies (BCAs) are developmental malformations of the head and neck region. Their histogenesis has been the subject of controversy and is not fully understood. This study aimed to test all present developmental theories ("branchial apparatus," "precervical sinus," "thymopharyngeal," and "inclusion" theories) on a sample of 48 BCAs from a single institution. METHODS: We performed a retrospective analysis of clinical-epidemiological and anatomical-pathological characteristics of BCAs treated over a 12-year period in our hospital. RESULTS: Overall, 46 patients (24 [52.17%] women and 22 men [47.83%]) underwent surgical excision of 48 BCAs. The mean patient age at presentation was 31.65 ± 19.40 years. Branchial cleft cysts were found in 42 (87.50%) cases, and branchial cleft sinuses were found in six (12.50%) cases. Eight (16.67%) BCAs were distributed in the preauricular region, 34 (70.83%) at the anterior border of the sternocleidomastoid muscle (SCM), three (6.25%) at the posterior border of the SCM, two (4.17%) in the suprasternal notch, and one (2.08%) in the retrosternal space. Histopathologically, 39 (81.25%) BCAs had a lymphoepithelial structure and nine (18.75%) BCAs had solitary epithelial cells. Inflammation and infection were observed in 24 (50%) and 12 (25%) cases, respectively. CONCLUSION: None of the hypothesized developmental theories fully explain the embryonic origin of BCA in our study sample. A possible explanation of BCA histogenesis is through the hybrid "branchial inclusion" theory.

Epidermoid and Dermoid Cysts of the Head and Neck.

ABSTRACT: Epidermoid and dermoid cysts (ECs and DCs) are congenital anomalies occurring in areas of embryonic fusion. Their incidence in the head and neck region is low and ranges from 1.6% to 7%. The aim of this study is to report on the clinical characteristics, treatment, and outcome of 22 patients from a single-institution experience. A retrospective analysis of patients treated for ECs and DCs of the head and neck over a 12-year period was performed. The present study included 22 patients (male/female ratio 1:1). The mean age of presentation was 11.68 years. The lesions were distributed in the orbital regions in 7 (31.82%) patients, auricular regions in 6 (27.27%), neck regions in 5 (22.73%), floor of the mouth in 3 (13.64%), and nose in 1 (4.55%). Complete surgical excision was performed as a definitive treatment method in 21 patients (95.45%). The mean size of the excised lesions was 21.36 mm at the widest length (range: 10-70 mm). On the basis of histopathological examinations, 15 (71.43%) lesions were classified as ECs and 6 (28.57%) as DCs. Post-operative complications were noted in 3 (14.29%) patients--2 (9.52%) with recurrences and 1 (4.76%) with hypertrophic scarring. All of these patients were successfully cured after a second surgery. The ECs and DCs of the head and neck present an interesting diagnostic and therapeutic challenge. Successful management depends on a thorough knowledge of their clinical and radiological features.

Congenital Neck Masses.

ABSTRACT: Congenital neck masses (CNMs) are developmental malformations that present with a wide spectrum of clinical symptoms and signs. They account for 21% to 45% of neck masses in children and 5% to 14% in adults. This study aimed to present the clinical manifestations and treatment of CNM from single-institution experiences. A retrospective analysis of patients surgically treated for CNM in a 12-year period was performed. Altogether, 117 patients (female/male ratio, 1:1.05) were diagnosed with CNM. The mean age at presentation was 26.91 years (range, 0.01-84 years). Within the study population, 120 CNMs were identified: 52 (43.33%) thyroglossal duct remnants, 48 (40.00%) branchial cleft anomalies, 7 (5.83%) epidermoid/dermoid cysts, 4 (3.33%) hemangiomas, 3 (2.50%) lymphangiomas, 1 (0.83%) hemangiolymphangioma, 1 (0.83%) hemangioendothelioma, 1 (0.83%) internal laryngocele, 1 (0.83%) external laryngocele, 1 (0.83%) ectopic thyroid gland, and 1 (0.83%) parathyroid cyst. The lateral neck region was the most frequently affected anatomical site, followed by the midline neck location and mediastinum (54%, 45%, and 1%, respectively). Surgical excision was performed in all cases. Recurrence was recorded in 5 (4.17%) patients. The results of this study provide comprehensive information regarding the clinical spectrum of CNM. Successful management of these lesions depends on a thorough understanding of neck embryology and anatomy. Misdiagnosis and improper treatment increase the morbidity and recurrence rate of CNM.

Tumor angiogenesis as an important prognostic factor in advanced non-small cell lung cancer (Stage IIIA).

The aim of the present study was to evaluate angiogenesis by determining the micro vascular density (MVD) and the expression of vascular endothelial growth factor (VEGF-A) in advanced non-small cell lung cancer (NSCLC) tumor samples, and to analyze their associations with clinical parameters and survival. Tumor tissue specimens of fifty patients (41 males and 9 females), who underwent radical surgical treatment for NSCLC in stage IIIA (T1-3N2) were collected for immunohistochemical analysis. MVD evaluation was performed using an anti-CD31 monoclonal antibody and VEGF-A expression using a polyclonal anti-VEGF-A antibody. The results were associated with two-year survival. Statistical analysis revealed significant associations in the level of angiogenesis (high MVD) and shorter survival of patients with NSCLC (P=0.0007). VEGF-A expression showed no association with micro vascular density (P=0.51) or survival (P=0.68). There was no significant association between MVD and VEGF-A. The measurable, clinical MVD parameters could be used as a reliable prognostic factor for the survival of patients with advanced NSCLC.

The Validity of Training Endoscopic Sinus and Skull Base Surgery Techniques on the Experimental Head Model.

OBJECTIVES: The aim of this study was to better understand the usual learning curve in acquiring endonasal endoscopic sinus and skull base surgery (ESSBS) techniques during the novice training on the lamb's head model. METHODS: Ten novices were asked to perform 10 bilateral dissections on the particular lamb's head each. The dissections were uniform, consisted of 10 well-defined steps, beginning from the simple removal of the inferior turbinate, and ending with more complicated procedures like cerebrospinal fluid leak repair, Draf 3 procedure for the frontal sinus and elevation of the nasal septal flap. The dissections have been supervised by experienced surgeons. A set of standard ESSBS instruments and 0° and 45° endoscopes have been used under the navigational system. The time required to complete each step has been measured in minutes. RESULTS: In general and quite expectedly, time rates have been obviously lowering as the number of the dissections performed has been growing in each of the participants. CONCLUSION: Training of the endonasal ESSBS techniques on the lamb's head proved to be useful for novices in getting basic surgical skills in the field. Because of the high degree of anatomic similarity and high level of the anatomic dimensions congruency between the lamb's head and human head (sheep's head has bigger dimensions!) it proved to be an essential preparation for the human cadaveric dissection. The median values of the time rates having been needed to complete the particular of the 10 steps in the last novices' dissections could be accepted as an orientation, just suggesting that once the time needed to complete 1 of the 10 steps has been and achieved by the particular novice, this could be an approximate sign of the maturity for the exercises on human cadaver head.

Sinus septi nasi: Anatomical study.

The aim of this study was to perform a pioneering investigation into the incidence of pneumatization in human skulls. A total of 93 human skulls (≥20 years of age, 69 males, 24 females) were included in the study. The skulls were scanned in a fixed position using cone beam computed tomography (CBCT). The pneumatized space parameters within the nasal septum-width, length, and height-were measured. Two types of finding were identified: (a) Pneumatization, named "sinus septi nasi" (SSN), and (b) "spongy bone" (SB). The results showed SSN in 32 of the 93 skulls (34.4%). The SSN formations were from 0.5 to 4.2 mm wide, 3.5 to 18.8 mm long, and 3.8 to 17.7 mm high. Tumefactions filled with SB were found in 61 of the 93 skulls (65.59%). These were not suitable for precise measurements since the outer borders were not strictly and well defined on CT scans (perhaps because of the preparation process). In conclusion, the perpendicular plate of the ethmoidal bone is not always compact bone; in 34.4% of cases, it shows a degree of pneumatization. In contrast, an enlarged formation filled with SB is present in 65.59% of cases. The possible sources of pneumatization of this little-investigated region are discussed: sphenoid sinus, frontal sinus, and vomeronasal organ. Clin. Anat. 30:312-317, 2017. © 2017 Wiley Periodicals, Inc.

An anatomical study of pneumatized crista galli.

The literature data on the incidence of pneumatization of the crista galli based on patients' computed tomography (CT) scans ranges from 3 to 37.5%. This study investigated for the first time the incidence of crista galli pneumatization based on CT scans of human skulls. The study examined 102 randomly selected human skulls (≥20 years of age; 76 males, 26 females). Skulls were scanned in a fixed position using cone beam computed tomography (CBCT) with a field of view of 145 × 130 mm and an isotropic voxel size of 0.25 mm. The scans were recorded in Digital Images and Communications in Medicine format. The CBCT images were analyzed using OnDemand3DTM software. A 2-mm contiguous slice thickness was used in the axial and coronal planes. The width, length, and height (cranial-caudal dimension) of the pneumatized space within the crista galli were measured. The crista galli was found to be pneumatized in even 68 (66.6%) of the 102 skulls. Two types of pneumatized crista galli (PCG) were identified: PCG alone (surrounded by bony walls) and PCG + spongiosis (surrounded by spongy bone). Of the 68 pneumatized skulls, 31 were PCG alone (45.58%) and 37 were PCG + spongiosis (54.42%). The pneumatized regions had a width of 0.9-6.6 mm, length of 2.8-12.9 mm, and height of 3.6-17.1 mm. No statistically significant differences have been found regarding the sex and age. Regarding the proportions of pneumatization, the three types of crista galli have been determined resulting in new, practical classification: type S (small), type M (moderate), and type L (large). The crista galli is not always a compact bone; in some cases, it is filled with spongy bone or pneumatized. In respect of proportions of pneumatization, there are three types of pneumatized crista galli: small, moderate, and large. Pneumatized crista galli can play an important role in clinical work, both as an inflamed sinus or other pathologies (sinusitis cristae galli, mucocoelae) or as a morphologic barrier in neurosurgical approaches to some tumors of the anterior skull base.

Lamb's head: The model for novice education in endoscopic sinus surgery.

Structured training in endonasal endoscopic sinus surgery (EESS) and skull base surgery is essential considering serious potential complications. We have developed a detailed concept on training these surgical skills on the lamb's head. This simple and extremely cheap model offers the possibility of training even more demanding and advanced procedures in human endonasal endoscopic surgery such as: frontal sinus surgery, orbital decompression, cerebrospinal fluid-leak repair followed also by the naso-septal flap, etc. Unfortunately, the sphenoid sinus surgery cannot be practiced since quadrupeds do not have this sinus. Still, despite this anatomical limitation, it seems that the lamb's head can be very useful even for the surgeons already practicing EESS, but in a limited edition because of a lack of the experience and dexterity. Only after gaining the essential surgical skills of this demanding field it makes sense to go for the expensive trainings on the human cadaveric model.

Type 5 and 6 nasal septal deformities: Could we predict and prevent acute coronary syndrome attacks in the future?

Undisturbed nasal breathing is essential for normal breathing physiology as a whole. Nasal septal deformities (NSD) are well known as a factor which can remarkably and substantially affect the quality of nasal and pulmonary breathing. However, it is well known that type 5 and type 6 nasal septal deformities may cause only a moderate, unilateral nasal obstruction or none at all. The effects of nasal obstruction on the respiratory and cardiovascular systems have been well studied so far: right ventricle problems, ischemic heart diseases, sleep disorders, mucociliary clearance system disturbances, paranasal sinus pathology, have all been described as a result of impaired nasal breathing. The connection between the upper and lower respiratory systems has been recognized in allergic rhinitis and asthma as well, resulting in the united airways concept. Most recently, the ostensible connection between chronic rhinosinusitis (CRS) and acute myocardial infarction has been said to be proven. However, the results of this study might have not been well founded since there are no direct and clear proofs that CRS as a chronic inflammatory process has anything to do with the acute coronary syndrome (ACS). On the other hand, a large international study on the incidence of NSD in CRS patients, based on the Mladina classification, showed that NSD were present in a high incidence and that the most frequent deformities were types 5 (36.18%) and 7 (29.92%). The vast majority of those types 7 consisted of types 3 and (again) types 5 or types 6 (76.32%). The fact that in CRS patients a remarkably high incidence of type 5 septal deformity can be seen, gives rise to thinking that this factor perhaps plays a role in the onset of ACS. Acute coronary syndrome is one of the leading causes of death all over the world. Traditional risk factors such as family history, overweight body, smoking, stress, hypertension, hypercholesterolemia, diabetes mellitus, coronary artery calcium score, C-reactive protein, lipoprotein, homocysteine, lipoprotein-associated phospholipase A2, as well as high-density lipoprotein functionality perhaps cannot account for the entire risk for incident coronary events. Several other potential risk factors have been identified in an effort to improve risk assessment for ACS. This article reviews one of them: the possible influence of an unusual, so far unknown predisposing factor: type 5 or type 6 nasal septal deformities. They have been found as pure, isolated types or as a part of combined nasal septal deformity (type 7).

Clinical Implications of Nasal Septal Deformities.

The first attempts to systematize septal distortions have been given by Cottle who defined four groups of septal deformities: subluxation, large spurs, caudal deflection and tension septum. Fortunately, the variations of the septal deformities show a certain order, thus enabling more precise classification. Mladina was the first to make user-friendly classification of septal deformities in six basic types. He also described the seventh type, named "Passali deformity", which presents individually, but is always a well-defined combination between some of the previous six types. Mladina types of septal deformities (SD) are divided in two main groups: so called "vertical" deformities (types 1, 2, 3 and 4), and "horizontal" ones (types 5 and 6). This classification was immediately well accepted by rhinologists worldwide and started to be cited from the very beginning. Since then it has been continuously cited increasingly more often, thus making Mladina classification a gold standard whenever clinical researches on nasal septum are concerned. More than forty clinical studies based on this classification have been performed to date. It is extremely important to make a strict distinction between the types of SD since all of them play some specific role in the nasal and general physiology in man.

International study of the incidence of particular types of septal deformities in chronic rhinosinusitis patients: the outcomes from five countries.

BACKGROUND: Chronic rhinosinusitis (CRS) may be more frequent in patients with particular types of septal deformities. The aim of this article was to investigate the incidence of particular types of septal deformities in adult CRS patients and healthy volunteers in various countries to determine whether some of them are more frequent in those groups. METHODS: This international multicentric study involved 505 subjects from five countries: Croatia, Romania, Italy, Russia, and Turkey. The types of septal deformities were observed and grouped according to the Mladina classification. Subjects were examined by means of native anterior rhinoscopy, anterior rhinoscopy after decongestion, and fiber endoscopy with topical anesthesia. CRS patients have been diagnostically proved by computed tomography scanning of the paranasal sinuses. RESULTS: Considering the CRS patients, the prevalence of so-called vertical deformities (types 2, 3, and 4) was seen. Among them, type 3 deformity was found most frequently in Turkey, Croatia, Italy, and Romania. CONCLUSION: Type 3 deformity has been found frequently in CRS patients in all five of the countries. Russian subjects exhibited a high frequency of type 4 deformity. Because this type consists of types 2 and 3, the later, again, has been proven to be prevalent in CRS patients also in this group of patients.

Training cerebrospinal fluid leak repair with nasoseptal flap on the lamb's head.

BACKGROUND: One of the major challenges of cranial base surgery is reconstruction of dural defects and cerebrospinal fluid leak closure. Various grafting methods have been used for smaller skull base defects with great success. The indications for endoscopic reconstruction have recently evolved to encompass much larger breeches in the skull base following tumor removal, thus emphasizing the need for vascularized tissue flaps for reconstruction. METHODS: Some authors proposed a pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium, which is very vascularized and has quite a large surface. It is also long enough to easily cover even larger defects of the skull base. The elevation of a nasoseptal flap is based on a particularly advanced surgical technique and thus requires proper training before being performed in a real patient. RESULTS: Anatomical differences between human and lamb heads were observed and explained although they do not affect the procedure of the elevation of the nasoseptal flap. CONCLUSIONS: The lamb's head has been shown to be an ideal model for the adequate training of the surgical skills required for this demanding procedure.

Influence of the menstrual cycle on the incidence of nausea and vomiting after laparoscopic gynecological surgery: a pilot study.

STUDY OBJECTIVE: To investigate whether the phase of menstrual cycle influences the incidence of postoperative nausea and vomiting (PONV) in women undergoing general anesthesia for elective laparoscopic gynecological surgery. DESIGN: Prospective, observational, blinded study. SETTING: General hospital, Postanesthesia Care Unit, and gynecologic floor room. PATIENTS: 111 ASA physical status 1 and 2 women, aged 18 to 53 years. INTERVENTIONS: Patients were classified into three groups according to the phase of menstrual cycle at the time of anesthesia: Group F1: follicular phase (menstrual days 1-8; n = 34); Group O2: ovulatory phase (days 9-15; n = 40); and Group L3: luteal phase (days 16 to end of cycle; n = 37). Anesthetic, postoperative pain management, and antiemetic regimens were standardized. MEASUREMENTS: Frequency of nausea, vomiting, or both were assessed for early (0-2 hrs). Late PONV (2-24 hrs) along with the use of rescue antiemetic, severity of nausea, and pain. MAIN RESULTS: In the follicular (n = 34), ovulatory (n = 40) and luteal phase (n = 37) groups, the frequencies of PONV over 24 hours were 35%, 38%, and 14% (P = 0.04), respectively. This was due to differences in the early postoperative period where the frequencies were 21%, 25%, and 3% (P = 0.02), respectively, as frequencies were similar in the late period (15%, 20% and 14%, P = 0.71), respectively. Nausea scores, rescue antiemetic usage, pain scores, and opioid consumption were similar in the groups. CONCLUSION: Patients in the luteal phase of their menstrual cycle may have a decreased risk of PONV after laparoscopic gynecological surgery in the early postoperative period.

Bilateral respiratory epithelial adenomatoid hamartoma of the olfactory cleft penetrating into the endocranium.

Respiratory epithelial adenomatoid hamartomas (REAHs) of the nose and paranasal sinuses are relatively rare. These tumors usually do not extend over the boundaries of the nose and sinuses. The authors presented a 65-year-old man experiencing progressive hyposmia, followed by intermittent stubborn headache. The symptoms lasted for almost 2 years and were getting worse very slowly. Fiberendoscopy showed relatively discrete polypoid tissue occupying the olfactory cleft bilaterally. The computed tomography and magnetic resonance imaging suggested the possible lack of the cribriform plate and the unity and uniformity of the tissues located both in the endocranium and high in the nasal cavity. The clinical picture resembled very much a esthesineuroblastoma.The patient underwent endoscopic sinus surgery under the general hypotensive anesthesia. Frozen sections during the surgery showed REAH. The entire tumor was removed in a piece meal way, including both olfactory bulbs because they were involved within the pathologic tissue as well.This case showed that REAH could also be a locally aggressive process, penetrating even into the endocranium.