The role of CT angiography and endovascular treatment in acute-massive head and neck bleeding.

PURPOSE: To report the results of the endovascular treatment of acute-massive head and neck bleeding in a single center and underline the value of computerized tomography-angiography and endovascular treatment of this desperate patient group. METHODS: Forty-eight patients who suffered from acute-massive head and neck bleeding and in whom conservative treatment options had failed were included in the study. To localize the site of the bleeding, computerized tomography-angiography was obtained above the supra-aortic level. Depending on the type and site of bleeding, an urgent angiographic evaluation and appropriate endovascular treatment procedure were performed in the same session immediately. Complete control of all active bleeding was determined as "technical success" at the end of the procedure. RESULTS: The majority of the endovascular treatment indications were tumoral mass bleedings in this study. Eight patients, all of which had head and neck tumors as the cause of the bleeding underwent repeated interventional procedures due to acute re-bleeding. All patients left the angiography unit with technical success and dramatic clinical improvement. Two patients had procedure-related severe complications, such as contrast-induced nephropathy and acute cerebrovascular accident. One patient died due to massive re-bleeding during the follow-up period. CONCLUSION: Computerized tomography-angiography is a successful imaging method to reveal the location and cause of bleeding. Endovascular treatment of acute-massive head and neck bleeding is an effective and life-saver treatment option that can be used successfully with relatively low-risk potential.

The role of CD133 expression of cancer stem cells on radiotherapy response in early stage glottic cancers.

PURPOSE: To investigate the relationship between CD133 positivity and radiotherapy (RT) response in early stage glottic laryngeal cancers. METHODS: Thirty seven patients with early-stage glottic laryngeal carcinoma who were treated with primary RT were evaluated. Patients with regular follow-up of at least 3 years were included in the study. Patients who had previously received chemotherapy for laryngeal surgery or underwent surgery were excluded. The patients were divided into two groups as recurrent and non-recurrent. These two groups were compared in terms of CD133 expression by immunohistochemical method. RESULTS: There were 37 patients in the study. Ten patients had recurrence and seven (70%) had CD133 positive and three had CD133 negative. Of 27 patients who had no recurrence, 16 (59%) had CD133 positive and 11 (41%) had CD133 negative. 7 (70%) of ten patients with recurrence were found to be positive for CD133; There was no statistically significant difference between recurrent and non-recurrent patient groups in terms of CD133 positivity (p > 0.05). There was no correlation between the final CD133 score and recurrence status as well (p > 0.05). CONCLUSION: There was no relationship between radiotherapy response and CD133 staining in early-stage glottic laryngeal cancers. It is the largest study about CD133 and RT sensitivity in early stage glottic carcinomas.

The effect of FoxP3 on tumour stage, treatment response, recurrence and survivalability in nasopharynx cancer patients.

OBJECTIVES: To investigate the relationship between the cell percentage of T regulator (Treg) cells of patients' specimens and disease severity, survivability, recurrence and metastasis in patients who were diagnosed with nasopharyngeal carcinoma (NPC). DESIGN, SETTING AND PARTICIPANTS: Sixty patients who were diagnosed as NPC and treated by the same protocol were enrolled to the study. Patient files were reviewed retrospectively and their clinical and pathological results were recorded. Deparaffinized samples of nasopharyngeal carcinoma patients were stained immunohistochemically with anti-FoxP3 monoclonal antibody. All patients's Anti-FoxP3 stained slides were evaluated by the same pathologist. Stained Treg lymphocytes around the tumoral foci were investigated. Patients were divided into two groups according to the total anti-FoxP3-stained Treg cell counts of the specimens; that is, less than 20% of the total or more than 20% of the total. These groups were compared statistically. MAIN OUTCOME MEASURES: Intensity of FoxP3 which is related to negative tumor response was the main outcome measure. It was evaluated in terms of stage, survival, recurrence and metastasis. RESULTS: The study group consisted of 42 male patients (70%) and 18 female patients (30%). The mean age was 47 ± 14.9. NPC subtypes among the patients were undifferentiated non-keratinized type in 54 patients (90%), differentiated non-keratinized type in 4 patients (6.66%) and keratinized type squamous cell carcinoma (SCC) in 2 patients (3.33%). When the two groups were compared in terms of pathological subtype, there was no significant variation between the two groups. There was also no significant variation between the two groups when compared on the basis of tumor stage (P = 0.36 for T phase, P = 0.122 for N phase), early stage, late phase (P = 0.15), survival rate (P = 0.69 for general survival), recurrence (P = 0.2 for local recurrence, P = 0.37 for regional recurrence) and distant metastasis (P = 0.3). CONCLUSION: There was no significant relationship between the concentration of these cells in the stained specimens and the disease stage, survival rate, recurrence and distant metastasis discovered.

Predictive value of E-cadherin and Ep-CAM in cervical lymph node metastasis of supraglottic larynx carcinoma.

OBJECTIVE: To evaluate the value of E-cadherin and epithelial cell adhesion molecule (Ep-CAM) expression in laryngeal biopsy materials for predicting cervical lymph node metastasis in patients with supraglottic laryngeal carcinoma. METHODS: All patients participating in the study were selected from among the surgically treated patients at the department of Otolaryngology, Head and Neck Surgery, Erciyes University School of Medicine between 1991 and 2005. The study consisted of thirty patients who had pathologically metastatic lymph nodes (pN+ group) and 30 age-, sex-, T value- and differentiation matched patients without pathologically metastatic lymph nodes (pN0 group). Immunohistochemical studies were performed with E-cadherin and Ep-CAM antibodies on representative tumor sections collected from paraffin sections of laryngeal biopsy materials. The expression of E-cadherin and Ep-CAM was compared between the pN0 and pN+ groups. The association between immunostaining of E-cadherin and Ep-CAM was also evaluated. RESULTS: There was no significant difference between the two groups in terms of E-cadherin and Ep-CAM expression. There was also a very poor agreement between the expression of E-cadherin and Ep-CAM. CONCLUSION: Multi-institutional and multidisciplinary immunohistochemical studies conducted with standardized methodology and also with more patient participation may help to obtain more specific results.

Survivin expression correlates with nodal metastasis in T1-T2 squamous cell carcinoma of the tongue.

In this study, the correlation between neck metastasis and recurrence was investigated by studying specimens of tongue squamous cell carcinoma patients immunohistochemical with survivin antibodies in the primary biopsy. A retrospective review was conducted at the Academic University Hospital. 46 patients who had squamous cell carcinoma of the tongue, who underwent various types of glossectomy and neck dissections between 1991 and 2008, were evaluated. The patient's sex, TNM staging, differentiation and recurrence rates were analyzed. There were 20 T1 patients and 26 T2 patients; 27 of the patients were N0 and 19 had metastatic lymph nodes in the neck. Survivin antibodies were applied with streptavidin-biotin method to the sections that were prepared from the primary tumor biopsy specimens of the patients. The correlation between neck metastasis and recurrence and survivins' immunohistochemical staining was analyzed with statistical methods. There were no significant differences between the patient's age, sex, tumor's T stage, tumor differentiation and survivin staining density. Survivin staining was positive in 15 (79 %) of 19 patients with neck metastasis, while it was positive in 16 (59 %) of 27 patients without neck metastasis. Eleven (79 %) of the 14 patients who had recurrence and all 6 patients who had neck recurrence only were stained by survivin. Expression of nuclear and cytoplasmic survivin can be a useful marker for predicting cervical lymph node metastasis in T1-T2 tumors in tongue SCC.

The Depth of Invasion and Level IV Cervical Node Metastasis in Patients with Clinically N0 Tongue Cancer.

BACKGROUND: The accurate indication for level IV dissection is crucial for preventing complications such as phrenic nerve damage and chylous fistulas in clinically N0 tongue cancer. Although the depth of invasion is an established independent risk factor for occult lymph node metastasis in tongue cancer, its relationship with level IV metastasis has not been evaluated. This study investigated the relationship between the depth of invasion and level IV nodal metastasis in clinically N0 tongue cancer. METHODS: We retrospectively investigated clinical N0 patients who underwent glossectomy and level I-IV neck dissection. We examined lymph node metastasis, risk factors, and the relationship between depth of invasion and metastasis. RESULTS: Our study included 58 patients, and no patient had isolated level IV metastasis. Additionally, there was no level IV metastasis in well-differentiated tumors. Tumor size, depth of invasion, differentiation, and perineural invasion were significantly associated with level IV neck metastasis. We found a critical tumor size of 2.5 cm and depth of invasion of 8 mm for level IV neck metastasis. CONCLUSION: Based on our findings, we recommend that level IV dissection should be considered for poorly differentiated tumors, tumors greater than 2.5 cm in size, and those deeper than 8 mm. This study highlights the importance of depth of invasion as a prognostic factor for predicting level IV metastasis and suggests that our findings can be used to prevent unnecessary level IV dissections that may lead to complications in tongue cancer surgery.

The role of CD44 and matrix metalloproteinase-9 expression in predicting neck metastasis of supraglottic laryngeal carcinoma.

AIM: The aim of this study is to evaluate the role of CD44 and matrix metalloproteinase (MMP)-9 expression in predicting neck metastasis of supraglottic laryngeal carcinoma. MATERIALS AND METHODS: Two hundred ninety-four supraglottic laryngeal cancers were treated surgically from 1991 to 2005. Ninety-four of the 294 patients had pathologically metastatic lymph node (pN+). Among the 94 patients, 30 pN+ patients were selected via random sampling. Sex-, T value-, and differentiation-matched 30 patients who had pathologically negative neck were also selected. CD44 and MMP-9 antibodies were applied to the tumor representative sections that were derived from paraffin sections by using the streptavidin-biotin method. The association between immunohistochemical results and histopathologic lymph node metastasis was analyzed statistically. The association between immunostaining of CD44 and MMP-9 was also analyzed. RESULTS: Overexpression of CD44 and MMP-9 was found to be significantly higher in pN+ patients. There was fair concordance between immunostaining of CD44 and MMP-9. CONCLUSION: Although wider multiinstitutional and multidisciplinary studies are needed to draw specific conclusions, CD44 and MMP-9 can be useful in the prediction of neck metastasis in the supraglottic laryngeal carcinoma.

Tularemia: a rare cause of neck mass, evaluation of 33 patients.

The objective of the study is to report 33 cases presenting with neck masses later diagnosed with tularemia and to raise attention to this rare zoonotic infection. A retrospective analysis of 33 patients, who were diagnosed with tularemia and treated at Erciyes University Department of Otorhinolaryngology between January 2010 and December 2010 was conducted. In conclusion, because tularemia is a rare infection, its diagnosis is frequently delayed and the symptoms of the patients may last for months without any appropriate treatment. The diagnosis of tularemia rests on clinical suspicion. For the patients, who carry risk factors for tularemia and having cervical lymphadenopathies with or without oropharyngeal symptoms and who do not response to treatment with beta-lactam antibiotics, tularemia must be kept in mind.

Regional metastatic pattern of papillary thyroid carcinoma.

The objective of the present study was to determine the pattern of lymphatic spread in papillary thyroid carcinoma with clinically positive nodes. Between 1999 and 2008, a total of 48 consecutive patients with clinical evidence of cervical lymph node metastasis of papillary thyroid carcinoma underwent 61 modified radical neck dissections (13 being bilateral) including levels II-VI. All neck dissection specimens were separated during surgery into levels and analysis was done with respect to the levels of neck. T value of tumor and demographic parameters were compared with the number of metastatic nodes with univariate analysis. The median number of pathologic nodes in neck dissection specimen was 7.0. The predominant site of metastasis was level VI (77%), followed by level III (69%), level IV (66%), and level II (46%). Level V showed 34% of nodal metastasis. Seven patients had level VII, and five patients had parapharyngeal lymph node dissections because of lymphatic involvement at these sites. There was no statistically significant correlation between T value, age, sex and the number of histologically positive lymph nodes (P = 0.39, P = 0.91 and P = 0.84, respectively). It was concluded that the high incidence of metastatic disease in levels II through VI supports the recommendation for level II through level VI neck dissection in patient with clinically positive neck disease.

Effect of nasal packing and haemostatic septal suture on mucociliary activity after septoplasty: an assessment by rhinoscintigraphy.

Nasal packing may influence the mucociliary clearance of the nose in the postoperative healing phase. In an attempt to overcome some of this problem, a haemostatic septal suturing technique was conceived. In this prospective study, we aimed to investigate the effects of nasal packing and septal suturing technique on mucociliary clearance by rhinoscintigraphy. Forty-eight adult patients who had undergone septoplasty were included in the investigation. Preoperatively, the patients were allocated into three groups: group 1, fingerstall packs filled with gauze and smeared with vaseline were used (11 male, 4 female); group 2, silicon septal splint packs were used (11 male, 4 female); group 3, haemostatic septal sutures were used (14 male, 4 female). Mucociliary clearance was measured by rhinoscintigraphy in all patients before surgery and 6 weeks after surgery. The nasal mucociliary clearance was presented as the velocity (mm/min) of nasal mucociliary transport of the (99m)Tc-MAA droplet. The mean velocity of nasal mucociliary clearances before and after surgery for group 1, group 2 and group 3 were 1.85 +/- 0.67 versus 2.43 +/- 0.78 mm/min, 2.36 +/- 0.80 versus 2.92 +/- 0.96 mm/min and 2.03 +/- 0.58 versus 2.62 +/- 0.65 mm/min, respectively. A significant difference in nasal mucociliary clearance was observed after surgery in all groups (p < 0.001). No significant differences were found between the groups regarding mucociliary clearance before and after surgery. Patients with septal deviation have a prolonged mucociliary transit time as compared with postoperative. Nasal packing did not significantly influence the mucociliary clearance in the postoperative healing phase.

The effect of arytenoid resection on functional results of cricohyoidopexy.

OBJECTIVE: The aim of this study was to evaluate the influence of arytenoid resection on voice and swallowing function in patients who undergo supracricoid laryngectomy with cricohyoidopexy. STUDY DESIGN: A case series with chart review. According to the arytenoid number, patients were divided into two groups: 11 patients with two arytenoids and 9 patients with one arytenoid. The decannulation, nasogastric tube removal, and hospitalization times were noted. Maximum phonation time, average fundamental frequency, percent jitter, percent shimmer, and noise-to-harmonic ratio were measured. Grade, roughness, breathiness, asthenicity and strain scale (for the perceptual evaluation of vocal quality), Voice Handicap Index (for self-assessment of the voice), and dysphagia score were used. RESULTS: The mean decannulation, nasogastric tube removal, and hospitalization time was 18.4, 40.2, and 32.7 days in patients with one arytenoid, whereas 8.8, 20.8, and 25.3 days in patients with two arytenoids, respectively. The differences were statistically significant. For all of the parameters that are associated with voice function and dysphagia, there was no statistically significant difference between one arytenoid and two arytenoids. CONCLUSION: Arytenoid resection may affect the swallowing function in the early postoperative period, but for voice and deglutition functions there was no difference between cricohyoidopexy with one arytenoid and two over the course of time.

Occult metastases from T1-T2 supraglottic carcinoma: role of primary tumor localization.

The present study was undertaken to evaluate the role of localization on the rate of occult metastasis in early stage supraglottic laryngeal carcinoma. We selected carefully 32 T1-2 clinically N0 patients without epilarynx involvement and 39 T1-2 clinically N0 patients with epilarynx involvement from among patients with supraglottic laryngeal carcinoma. All patients underwent simultaneous unilateral or bilateral neck dissection with laryngeal surgery. The rate of the occult metastases was 3.1% in patients without epilarynx involvement, whereas it was 20.5% in patients with epilarynx involvement. Within the supraglottic larynx, two subregions can be distinguished: the epilarynx and the lower supraglottis. Our results suggest the possibility of omitting elective neck treatment in T1-2N0 supraglottic laryngeal carcinoma without epilarynx involvement. Observation under strict follow-up may be an option to routine neck treatment in T1-2N0 supraglottic laryngeal carcinoma without epilarynx involvement.

[Head and neck cancers in geriatric patients]. / Yaslilarda bas boyun kanserleri.

Cancer is a disease the incidence of which rises with age. Given that the risk of developing cancer increases with advancing age, a growing number of elderly patients will need treatment for cancer in the future, and head and neck surgeons are increasingly being faced with therapeutic dilemmas regarding this age group. Related publications show that older patients are less likely than younger patients to receive standard treatment. Therapeutical planning must be based not only on tumor characteristics, but also on the physiological, rather than the chronological, age of the patient. Comorbidity is the most important factor in less intensively treatment of elderly patients. Complete geriatric assessment and a multidisiclinary approach are the crucial points. Surgeons, radiation therapy specialists, medical oncologists and geriatricians must actively cooperate in this setting. Recruitment of elderly cancer patients to more clinical trials is needed to enhance our knowledge and to offer optimum treatment to this unique subgroup.

Bilateral Laryngocele Causing Epiglottic Deformity and Upper Airway Obstruction.

Laryngocele is the cystic dilatation of laryngeal ventricle. Most cases are asymptomatic and incidentally diagnosed in radiologic examinations. Although the etiology is unclear, obstruction, laryngeal pressure, congenital defects are possible risk factors. Computed tomography is the best method for diagnosis. Endoscopic, external or combined approaches have been described in the surgical treatment. Laryngocele should be kept in mind in patients with acute upper airway obstruction. Such patients may require tracheostomy. Some patients with laryngocele can also have laryngeal cancer, in which case direct laryngoscopy must be performed. This report presents a case with respiratory distress associated with bilateral laryngocele, and his management in the light of the literature.

[Head and neck paragangliomas]. / Bas-boyun paragangliomlari.

OBJECTIVES: We evaluated patients who were treated for head and neck paragangliomas. PATIENTS AND METHODS: The study included 40 patients (25 females, 15 males; mean age 48 years; range 26 to 74 years) who were operated on for paragangliomas of the head and neck region between 1993 and 2007. Clinical findings, treatment modalities, and the results of treatment were evaluated. RESULTS: The most common complaint was neck swelling (n=30), followed by tinnitus (n=7), hearing loss (n=6), imbalance (n=3), pain (n=2), hoarseness (n=2), and nasal obstruction (n=1). The mean duration of symptoms was 22 months. The most common paraganglioma was glomus caroticum (n=28) with a mean tumor diameter of 4.5 cm (range 2 to 12 cm). Urinary vanilmandelic acid concentration was measured in 24 patients and found above normal range in two patients. Octreotide scintigraphy was performed in 14 patients and femoral angiography was performed in 27 patients. Multicentric disease was present in one patient and one patient had bilateral involvement. Transcervical excision was the most common approach. Complications were as follows: transient facial nerve paresis (n=3), vagal nerve palsy (n=2), hypoglossal nerve palsy (n=2), permanent facial paralysis (n=1), bleeding (n=1), and total hearing loss (n=1). No recurrences were encountered during a mean follow-up of 71 months. CONCLUSION: Preoperative evaluation of all patients with respect to catecholamine secretion and multicentric disease is important for choosing the proper treatment and preventing possible complications.

[Thyroid masses: an analysis of 131 cases]. / Tiroid kitleleri: 131 olgunun degerlendirilmesi.

OBJECTIVES: We retrospectively analyzed patients undergoing surgery for thyroid masses. PATIENTS AND METHODS: A total of 131 patients (80 males, 51 females) who underwent surgery for thyroid masses between 1993 and 2007 were evaluated with respect to clinical findings, histopathologic diagnoses, and treatment modalities. RESULTS: The thyroid masses were found benign in 48.1% and malignant in 51.9% of the patients. Forty-one females (65%) and 22 males (35%) had benign thyroid masses, while 39 females (57%) and 29 males (43%) had malignant thyroid masses. According to histopathologic results, the most common benign and malignant diagnoses were multinodular goiter (n=57, 43.5%) and papillary carcinoma (n=50, 38.2%), respectively. The mean duration of complaints was 58 months for benign and 30 months for malignant tumors. CONCLUSION: Thyroid operations are becoming increasingly common in otorhinolaryngologic surgical procedures.

Is routine inclusion of level IV necessary in neck dissection for clinically N0 supraglottic carcinoma?

OBJECTIVE: Elective level II to IV dissection has become a common practice for patients with N0 neck and supraglottic laryngeal carcinoma. Several authors have questioned the necessity of dissecting level IV and the possible risk of associated morbidities such as chyle leak and phrenic nerve injury. STUDY DESIGN AND SETTING: We reviewed 58 patients who underwent elective functional and lateral neck dissection for supraglottic carcinoma. Node levels were delineated just after the removal of the specimens. The patients were followed at least 3 years postoperatively or until the time of death; recurrence rates and levels were evaluated. RESULTS: Occult lymph node metastases were determined in 14 cases. Level II was the most involved zone (7 patients). Isolated level IV lymph node metastasis was not established. CONCLUSION: We think that routine level IV dissection is not necessary in the management of clinically and radiologically N0 necks in patients with supraglottic laryngeal carcinoma.

[Spinal accessory nerve functions after functional and lateral neck dissections: an electromyographic study]. / Fonksiyonel ve lateral boyun diseksiyonu sonrasinda spinal aksesuvar sinir fonksiyonlari: Elektromiyografik çalisma.

OBJECTIVES: This study was designed to determine electromyographic findings of the spinal accessory nerve (SAN) after elective functional (level II-V) and lateral neck dissections (level II-IV) in N0 patients with supraglottic larynx carcinoma. PATIENTS AND METHODS: The study included 10 patients (five bilateral) who underwent functional (FND), and 10 patients (all bilateral) who underwent lateral (LND) neck dissection for supraglottic larynx carcinoma. Those with a history of myopathy, neuropathy, recurrent disease, or previous radiotherapy were excluded. Functions of the SAN were evaluated with EMG after at least 12 months postoperatively. The results were assessed in four groups as normal functions, or neurogenic deficit of mild, moderate, or severe degree. RESULTS: Neurogenic deficits were found in the sternocleidomastoid muscle in eight necks (53.3%) and in the trapezius muscle in seven necks (46.6%) in the FND group. However, only two necks (10%) exhibited neurogenic deficits affecting both muscles in the LBD group. Comparison between the two groups showed a significant difference in terms of SAN functions (p<0.05). CONCLUSION: Compared to FND, LND is associated with significantly less neurogenic damage secondary to SAN dissection.

[Adenoidal vegetations in adults: an evaluation of 12 cases]. / Eriskinlerde görülen adenoid vejetasyonlar: 12 olgunun degerlendirilmesi.

OBJECTIVES: We evaluated the clinical significance of adenoidal vegetations which are overlooked as a cause of nasal obstruction in adults. PATIENTS AND METHODS: The study included 12 patients older than 15 years of age (10 males, 2 females; mean age 23.5 years; range 15 to 32 years) who presented with nasal obstruction due to adenoidal vegetations. The patients were evaluated with respect to age, sex, complaints, findings of physical examination, computed tomography of the nasopharynx, and nasal endoscopy, and histopathologic results. RESULTS: All the patients had nasal obstruction. The most common symptom was snoring. Physical examination showed a vegetative mass in the posterior wall of the nasopharynx obstructing the choana. Five patients had bilateral serous otitis media and eight patients had postnasal purulent drainage. All the patients underwent adenoidectomy under general anesthesia and with transnasal endoscopic control. Histopathologic examination of surgical specimens showed lymphoid hyperplasia. CONCLUSION: Although adenoidal tissue undergoes regression toward the adolescent period, it may present as the chief cause of nasal obstruction in adults.

Thyroid leiomyosarcoma: presentation of two cases and review of the literature.

INTRODUCTION: Leiomyosarcoma is a tumor which is rarely seen in the thyroid gland. The diagnosis may be difficult and the treatment is controversial. OBJECTIVE: The objective of the study is to review the literature about a rare malignant disease of the thyroid gland which has high mortality. METHODS: Two cases of thyroid leiomyosarcoma are presented and the previous 23 cases in the current literature are reviewed. RESULTS: A total of 25 cases of thyroid leiomyosarcoma are reviewed; the most common complaint was rapidly growing anterior neck mass, and ten of the 25 patients had distant metastasis at the initial admission. Fifteen of the 25 patients died with the disease in the first 12 months after the diagnosis. CONCLUSION: The differential diagnosis of thyroid leiomyosarcoma is important and should be performed with other malignancies of the gland, especially with anaplastic carcinoma. The prognosis is poor and there is no consensus regarding the treatment.