GUNSHOT INJURIES OF THE OROFACIAL REGION.

Between 2000 and 2010, approximately 10,000 gun attacks resulting in death were registered in the EU countries. In the same period and region, approximately 40,000 suicides took place, 1,500 of which were in the Czech Republic. 82% of suicides or suicide attempts using a firearm (or another projectile weapon) led to a head injury. Typically, the shots target the temporal or submental region. The severity of the suffered injuries depends besides the wound site, projectile calibre and energy also on other factors such as the projectile trajectory, formation of secondary projectiles, shot reflection from the skeletal structures, etc. Gunshot wounds aimed at the splanchnocranium usually lead to injuries of the mandible(s), maxilla(e), orbit(s) and nose, i.e. of regions associated with multiple fields of medicine requiring multidisciplinary cooperation. The presented paper aims to explain in detail the destructive effects of gunshot injuries in the orofacial regions and to describe the recommended procedure during primary medical treatment. The team of authors aimed to clearly present important information originating both from literature and practical experience with this type of injury.

Comparison of narrow band imaging and the Storz Professional Image Enhancement System for detection of laryngeal and hypopharyngeal pathologies.

OBJECTIVE: The aim of this study was to compare narrow band imaging (NBI) endoscopy and Storz Professional Image Enhancement System (SPIES) in observing epithelial and/or subepithelial microvascular irregularities and pathologies. METHODS: A total of 73 patients with laryngeal or hypopharyngeal lesions were investigated using high-definition NBI endoscopy preoperatively in local anesthesia and using SPIES system intraoperatively in general anesthesia from August 2016 to October 2017. Superficial vascular structures were classified preoperatively (NBI) and intraoperatively (SPIES) according to descriptive guidelines of vascular changes by Arens. All lesions were endoscopically evaluated and divided according to the histological examination into four groups (A-benign lesions, B-recurrent respiratory papillomatosis, C-low-grade dysplasia, D-high-grade dysplasia, carcinoma in situ or invasive squamous cell carcinoma), and results were compared with NBI and SPIES optical biopsy. RESULTS: Benign lesions (polyps, cysts, chronic inflammation, hyperkeratosis) were histologically confirmed in 26/73 (35.6%) cases and identified by NBI in 20/26 lesions (76.9%) and in 20/26 cases (76.9%) by SPIES, respectively. Recurrent respiratory papillomatosis was confirmed in 16/73 (21.9%) and detected in 15/16 cases (93.8%) by NBI and in 16/16 cases (100.0%) by SPIES. Low-grade dysplasia (mild and moderate dysplasia) was histologically detected in 7/73 patients (9.6%) and accurately identified by NBI in 6/7 (85.7%) and by SPIES in 6/7 (85.7%) cases, respectively. Histopathological features of severe dysplasia, carcinoma in situ or invasive squamous cell carcinoma were detected in 24/73 (32.9%) patients. According to the NBI endoscopy the suspected vascular neoangiogenesis was recognized in 19/24 cases (79.2%) and in 18/24 cases (75.0%) using SPIES endoscopy. Sensitivity and specificity of NBI endoscopy and SPIES system in correct prediction of histological diagnosis of already detected lesions were 83.0 and 98.0% and 86.0 and 96.0%, respectively. Results of NBI/SPIES endoscopy and histopathological features of laryngeal and hypopharyngeal lesions were compared and the level of agreement was 81.43%, kappa index κ = 0.7428 (95% CI 0.682-0.832) (p < 0.001) by NBI endoscopy and 81.16%, kappa index κ = 0.7379 (95% CI 0.638-0.880) (p < 0.001) by SPIES endoscopy, respectively. The agreement was confirmed as substantial and strong. Level of agreement of both endoscopic methods was 92.54%, kappa index κ = 0.8965 (95% CI 0.877-0.954) (p < 0.001), agreement was confirmed as almost perfect. Between NBI and SPIES endoscopic imaging methods is no significant differentiation. CONCLUSION: Both methods, NBI endoscopy and SPIES system, are comparable in detection and analysis of superficial neoangiogenesis, typical for benign lesion and for precancerous or cancerous changes in larynx and hypopharynx.

The role of narrow-band imaging (NBI) endoscopy in optical biopsy of vocal cord leukoplakia.

The aim of this study was to investigate whether observing microvascular changes by narrow-band imaging (NBI) endoscopy in the area surrounding leukoplakia is sufficient for discriminating between benign and malignant patterns of vocal cord leukoplakia. A total of 282 patients were investigated using white-light high-definition TV laryngoscopy and NBI endoscopy from 6/2013 to 8/2015, and 63 patients with a primary case of laryngeal leukoplakia were enrolled. Patients were divided into two groups based on leukoplakia with surrounding malignant intraepithelial papillary capillary loops (group I; 26/63) and leukoplakia with a surrounding benign vascular network (group II; 37/63), both by NBI endoscopy. All 63 patients were evaluated by blinded histological examination, and results were compared with NBI optical biopsy. Carcinoma in situ or invasive squamous cell carcinoma was confirmed in 22/26 cases (84.6 %) in group I. Hyperkeratosis or low-grade dysplasia was confirmed histologically in 31/37 (83.8 %) and squamous cell carcinoma in 2/37 (5.4 %) cases in group II. Accordance of NBI endoscopy and histopathological features of vocal cord leukoplakia lesions was statistically significant (kappa index 0.77, p < 0.001), with a sensitivity of 88.0 % (95 % CI 67.8-97.5 %) and specificity of 89.5 % (95 % CI 71.2-97.1 %). NBI is convenient for improving evaluation of laryngeal leukoplakias based on optic prehistological diagnosis. The close accordance between NBI features and histological results suggests that a negative NBI endoscopy may be an indication for long-term endoscopy follow-up without histological evaluation.

Laryngopharyngeal reflux and herpes simplex virus type 2 are possible risk factors for adult-onset recurrent respiratory papillomatosis (prospective case-control study).

OBJECTIVE: The human papillomavirus (HPV) causes recurrent respiratory papillomatosis (RRP). Although HPV prevalence is high, the incidence of papillomatosis is low. Thus, factors other than HPV infection probably contribute to RRP. This study investigated whether patients with papillomatosis are more often infected with herpes simplex virus type 2 and chlamydia trachomatis (ChT) and whether laryngopharyngeal reflux (LPR) occurs in this group of patients more often. DESIGN: Prospective case-control study. SETTING: Department of Otorhinolaryngology of University Hospital. PARTICIPANTS: The study included 20 patients with adult-onset RRP and 20 adult patients with vocal cord cyst and no pathology of laryngeal mucosa (control group). MAIN OUTCOME MEASURES: Immunohistochemical analysis of pepsin, HPV, herpes simplex virus type 2 and ChT was performed in biopsy specimens of laryngeal papillomas and of healthy laryngeal mucosa (control group) obtained from medial part of removed vocal cord cyst during microlaryngoscopy procedures. RESULTS: Pathologic LPR (pepsin in tissue) was diagnosed in 8/20 (40.0%) patients with papillomatosis and in 0/20 control patients (P = .003). Herpes simplex virus type 2 was present in 9/20 (45.0%) patients with papillomatosis and in 0/20 control patients (P = .001). Five specimens were positive for both pepsin and herpes simplex virus type 2. No samples were positive for ChT. There were no significant differences between groups for age, body mass index, diabetes mellitus and gastrooesophageal reflux disease. Tobacco exposure was not more frequent in RRP group either (P = .01). CONCLUSIONS: Results show that LPR and herpes simplex virus type 2 are significantly more often present in patients with RRP. LPR and herpes simplex virus type 2 might activate latent HPV infection and thereby be possible risk factors for RRP.

[Intensity Modulated Hyperfractionated Accelerated Radiotherapy to Treat Advanced Head and Neck Cancer - Predictive Factors of Overall Survival]. / Hyperfrakcionovaná akcelerovaná radioterapie s modulovanou intenzitou u pokrocilých nádoru hlavy a krku - prediktivní faktory celkového prezití.

AIM: The aim of this study was to evaluate overall survival (OS) and prognostic factors in patients ineligible for chemotherapy who were treated with a hyperfractionated accelerated schedule with simultaneous integrated boost. MATERIAL AND METHODS: From May, 2008, to April, 2013, 122 patients with locally advanced nonmetastatic squamous laryngeal (14%), hypopharyngeal (30%), oropharyngeal (30%), and oral cavity (27%) cancer were treated at our institution. The median age, Karnofsky Performance Status (KPS), and gross tumor volume (GTV) of the patients were 63 years (range, 46-87 years), 80% (range, 50-100%), and 46 ml (range, 5-250 ml), resp. The median total dose of radiotherapy was 72.6 Gy (range, 62-77 Gy) at 1.4-1.5 Gy per fraction, and 55 Gy at 1.1 Gy per fraction was delivered for GTV (primary and lymphadenopathy) with a margin of 0.7 cm and regional lymphatic areas with a margin of 0.3 cm. The dose was delivered 2× a day, with a 6-8 hour interval between doses, via a 6 MeV linear accelerator. OS was estimated using the Kaplan-Meier method, and predictors of OS were analyzed using Cox proportional hazards regression. RESULTS: The median duration of the radiotherapy series was 37 days (range, 32-45 days). The incidence of grade 3 acute toxicity was 62% for mucosa (oral cavity and/or pharynx) and 0% for skin. Confluent mucositis cleared in all cases within 21 days. No grade 4 or 5 toxicities were recorded. PEG was introduced before treatment in 55 patients (45%). The 1-and 2-year OS was 65% and 32%, resp. KPS less than 80% (RR 2.4, 95% CI 1.3-4.2; p = 0.004), cancers other than oropharyngeal or laryngeal cancer (RR 2.0, 95% CI 1.1-3.5; p = 0.016), and capacity of high GTV (RR 1.006, 95% CI 1.001-1.011; p = 0.017) were found to be negative prognostic factors for OS. CONCLUSION: More than 30% of patients with poor prognosis survived for longer than 2 years. KPS before treatment was the strongest prognostic factor for better OS.Key words: head and neck cancer - radiotherapy dose fractionation - survival analysis - acceleration - hyperfractionation This work was supported by RVO-FNOs/2016 (HPV status as predictive and prognostic factor for primary and secondary head and neck cancer). The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 9. 3. 2017Accepted: 19. 4. 2017.

[Value of narrow band imaging endoscopy in detection of early laryngeal squamous cell carcinoma]. / Vyuzití Narrow Band Imaging v dia-gnostice casných karcinomu hrtanu.

BACKGROUND: Narrow band imaging (NBI) is an endoscopic method using filtered wavelengths in detection of microvascular abnormalities associated with preneoplastic and neoplastic changes of the mucosa. The aim of the study is to evaluate the value of NBI endoscopy in the dia-gnosis of laryngeal precancerous and early stages of cancerous lesions and to investigate impact of NBI method in prehistological diagnostics in vivo. MATERIALS AND METHODS: One hundred patients were enrolled in the study and their larynx was investigated using white light HD endoscopy and narrow band imaging between 6/ 2013- 10/ 2014. Indication criteria included chronic laryngitis, hoarseness for more than three weeks or macroscopic laryngeal lesion. Features of mucosal lesions were evaluated by white light endoscopy and afterwards were compared with intra-epithelial papillary capillary loop changes, viewed using NBI endoscopy. Suspicious lesions (leukoplakia, exophytic tumors, recurrent respiratory papillomatosis and/ or malignant type of vascular network by NBI endoscopy) were evaluated by histological analysis, results were compared with prehistological NBI dia-gnosis. RESULTS: Using NBI endoscopy, larger demarcation of pathological mucosal features than in white light visualization were recorded in 32/ 100 (32.0%) lesions, in 4/ 100 (4.0%) cases even new lesions were detected only by NBI endoscopy. 63/ 100 (63.0%) suspected lesions were evaluated histologically -  malign changes (carcinoma in situ or invasive carcinoma) were observed in 25/ 63 (39.7%). Prehistological diagnostics of malignant lesions using NBI endoscopy were in agreement with results of histological examination in 23/ 25 (92.0%) cases. The sensitivity of NBI in detecting malignant lesions was 89.3%, specificity of this method was 94.9%. CONCLUSION: NBI endoscopy is a promising optical technique enabling in vivo differentiation of superficial neoplastic lesions. These results suggest endoscopic NBI may be useful in the early detection of laryngeal cancer and precancerous lesions.

[Stevens-Johnson syndrome - a case report]. / Stevensuv-Johnsonuv syndrom-kazuistika.

Stevens-Johnson syndrome (SJS) is a severe skin and mucosal condition, with eruption of hemorrhagic vesiculous to bullous lesions, caused by hypersensitive reaction to certain drugs; rarely, it can be parainfectious. SJS is a minor form of toxic epidermal necrolysis, with involvement of less than 10 % of the skin surface. Cutaneous and mucosal lesions are caused by necrosis of epithelial cells induced by T lymphocytes. The diagnosis is based on clinical features but it has to be confirmed by histologic and immunohistologic examination of the lesions. The treatment consists of high doses of systemic corticosteroids and particularly thorough local, supportive and symptomatic therapy. The authors present a case of parainfectious SJS and discuss the latest knowledge about SJS as well as therapeutic options.

Revison endonasal dacryocystorhinostomies: analysis of 44 procedures.

PURPOSE: To determine the success rate of revision endoscopic dacryocystorhinostomies (DCR) and to analyse 44 revision DCRs. METHODS: The operative and postoperative data were collected in 44 revision DCRs. The corrections of associated structural anatomic alterations were performed during the surgery (resection of the scarr, the bone window creating, resection of the head of the middle turbinate, septoplasty, ethmoidectomy etc.) and the intubation was performed in all cases. RESULTS: The follow-up interval ranged from 12 to 36 months. The 44 ReEDCRs were performed in adults and there were only 5 children under the age of 15. The surgery was performed under local or general anaesthesia. The most frequent secondary procedures were scar resections, creating a wider bone window, and partial middle turbinate resection. Four patients were excluded for their follow-up periods had not been completed. An average time of the tubes removal was 5.6 months. The total success rate was 84.0%; the success rate was 85.7% in the group with closed rhinostomy and 1/2 in the group of canalicular and rhinostomy obstructions. CONCLUSIONS: The endonasal revision DCR is a safe and very effective surgical procedure following the failed DCRs. The correction of associated structural anatomic alterations that may be involved in the failure of previous surgeries can be easily performed.

Saline injection to determine the volume required for personalised patulous Eustachian tube augmentation with long-standing material.

OBJECTIVE: There is currently no general consensus on patulous Eustachian tube management. Injection of autologous fat, cartilage or hydroxylapatite has been described for Eustachian tube occlusion, with promising results. However, complete resolution of symptoms is not achieved in all cases. This could be connected to the amount of material injected into the surroundings of the Eustachian tube, as this greatly differs among existing studies. Identifying the appropriate volume of injected material could be challenging because anatomical conditions vary among patients, and there is always a risk of chronic Eustachian tube obstruction and its related complications when too much long-standing material is injected.Case reportA case is presented wherein saline was injected under local anaesthesia to determine the volume required and to predict the success of patulous Eustachian tube augmentation with long-standing material. CONCLUSION: This approach could allow more personalised treatment and help identify patients likely to benefit from the procedure.

There is no correlation between signs of reflux laryngitis and reflux oesophagitis in patients with gastro-oesophageal reflux disease symptoms.

The objective of the present study was to determine if there is correlation between signs of reflux laryngitis (RL) and reflux oesophagitis (RE) in patients with gastro-oesophageal reflux disease (GORD) symptoms. Laryngeal photography obtained from patients during oesophagogastroduodenoscopy were examined by two otolaryngologists experienced in the field of extra-oesophageal reflux regarding the presence and severity of RL. The presence of RE was evaluated by gastroenterologist. Smokers, heavy drinkers and patients with bronchial asthma were excluded from the statistical analysis. A total of 681 patients were analysed. RL was diagnosed in 367 (53.9%) cases, of whom 182 patients had mild, 118 moderate and 67 severe (Reflux Finding Score > 7) RL. RE was diagnosed in 103 (28.1%) patients with RL and in 80 (25.7%) patients without RL. Neither the difference between the overall group of patients with RL and those without (OR 1.141, 95% CI 0.811-1.605, p = 0.448), nor the differences between the respective subgroups of patients with mild, moderate and severe RL and those without RL were statistically significant. The OR and 95% CI for mild, moderate and severe RL were 1.042, 95% CI 0.712-1.526, p = 0.834, 1.182, 95% CI 0.764-1.831, p = 0.453 and 1.0, 95% CI 0.566-1.766, p = 0.999 respectively. It can be concluded that there is no correlation between RL and RE in patients with GORD symptoms.

Cutaneous listeriosis in a veterinarian with the evidence of zoonotic transmission--a case report.

A case of Listeria monocytogenes skin infection in a man is presented. A 54-year-old male veterinary practitioner developed pustular changes on the skin of arms and hands after assisting with the delivery of a stillborn calf. Listeria monocytogenes was isolated from the skin lesions on the arms and from the bovine placenta. Listeria monocytogenes isolates were serotyped and genotyped with pulsed-field gel electrophoresis (PFGE) to confirm the suspected transmission of the pathogen from animal to human. All isolates were of serotype 4b with identical pulsotype. To the best of our knowledge, this is the first case of cutaneous listeriosis in which the evidence for zoonotic transmission of L. monocytogenes is supported by genotyping methods.

[Transnasal endoscopic surgery approach in intraorbital tumors]. / Transnazální endoskopická chirurgie nádoru ocnice.

OBJECTIVES: To determine the role of transnasal endoscopic approach to orbital lesions. METHODS: Retrospective case series. RESULTS: Three patients underwent endoscopic diagnostic surgery for orbital lesions. In all three patients was successfully finded out the diagnosis, the orbita was decompressed. In two cases it resulted to visual recovery, in one case was determine a diagnosis of metastatic adenocarcinoma. In one case the tumor was removed totally. CONCLUSION: Using endoscopic approach to the orbit allowed good approach to the biopsy of orbital lesions, allowed decompression an in limited count of cases this access allowed a complete tumour removal. On the other hand, generally endoscopic approach is useful only for limited lesions (extraconal), usually it allowed only debunking, not the complete resection of orbital pathology.