Role of nasal cytology.

Nasal cytology represents a valid method in the differential diagnosis of allergic and non-allergic nasal diseases, as it is simple, safe, non-invasive, cost-effective, and easy to perform both in the medical and paediatric office. In particular, through cytological investigation it is possible to diagnose a group of non-allergic infective rhinitis that still today constitutes a vague aspect of the clinical-diagnostic-therapeutic approach to eosinophilic non-allergic rhinitis (NARES), non-allergic rhinitis mast cell (NARMA), neutrophilic non-allergic rhinitis (NARNA), and eosinophil-mast cell non-allergic rhinitis (NARESMA). Preventive treatment of nasal diseases, when guided by rhinocytograms, leads to a favorable clinical and time-dependent outcome. These advantages are reflected in a better quality of life and in a reduction in National Health Service costs, without chronic evolution of the disease to complications.

Nasal-sinus polyposis: clinical-cytological grading and prognostic index of relapse.

This longitudinal and prospective study aimed at investigating the influence of some parameters,including nasal cytology and clinical findings (such as asthma, atopy, acetylsalicylic acid (ASA) sensitivity, ASA associated with asthma), as risk factor of post-surgical relapse of nasal-sinus polyps. One hundred sixty-one consecutive patients (92 males and 69 females, mean age 47 years), affected by bilateral nasal polyposis and who had undergone surgical nasal polypectomy (endoscopic FESS), were examined post-surgically at least every 6 months for a period of 10 years. Endoscopic exam and nasal cytology exam were carried out on all patients and their case histories were carefully examined. The association eosinophilic-mast cell cellularity and the contemporary presence of asthma + ASA sensitivity showed the highest level of relapse (OR 4.5). In conclusion, cytological data in association with certain clinical parameters can predict a high risk prognosis of relapse.

Non-allergic rhinitis with eosinophils and mast cells constitutes a new severe nasal disorder.

Three main types of inflammatory Non-Allergic Rhinitis (NAR) have been defined: NAR infiltrated by eosinophils (NARES), by mast cells (NARMA), and by neutrophils (NARNE). A new particular type has been characterized with current infiltration by eosinophils and mast cells (NARESMA). The aim of this study is to evaluate the clinical and functional characteristics in patients with NARES, NARMA, NARNE, and NARESMA and to define the latter. One hundred and seventy-six NAR patients were prospectively and consecutively evaluated: 52 patients with NARES, 38 with NARMA, 36 with NARNE, and 50 with NARESMA. Clinical features, Quality of Life (QoL), and rhinomanometry were evaluated in all of them. QoL was significantly different in the 4 groups. NARESMA patients had the worst QoL. Nasal function and QoL in NARESMA patients were significantly correlated. Significant associations were shown with both nasal polyps and asthma in NARESMA patients. This study provides the first evidence that NARESMA constitutes a new type of NAR and is a particularly severe disorder.

[Glucan solution nasal spray vs saline in the treatment of chronic rhinosinusitis: a multi-centric double blind randomised clinical trial]. / Soluzione spray nasale di glucano vs soluzione fisiologica nel trattamento della rinosinusite cronica: studio multicentrico in doppio cieco randomizzato.

OBJECTIVES: The aim of our study was to evaluate the efficacy of 30 days treatment with glucan solution nasal spray vs. saline in the treatment of signs and symptoms of chronic rhinosinusitis. MATERIALS AND METHODS: 100 patients affected by chronic rhinosinusitis were enrolled. At the beginning and at the end of the study were evaluated: nasal congestion, headache, rhinorrea, facial pain, rhinopharyngeal exudate, inferior turbinate hypertrophy; a complete instrumental analysis of nasal functions by Active Anterior Rhinomanometry, nasal Muco-Ciliary Transport time and scraping of nasal mucosa was also performed. The patients were randomized 1:1 for receiving intranasal saline or intranasal glucan solution spray. Treatment was administered as follows: 2 puffs/nostril 3 times a day for 30 days. RESULTS: The patients in therapy with the glucan solution showed a significant improvement concerning rhinorrea facial pain, intensity of headache, inferior turbinate hypertrophy, rhinopharyngeal exudates, inspiratory/expiratory nasal resistences, Muco-ciliary transport time, normalization of nasal mucosas and rhinocytogram; saline lavage didn't show this effects. Both treatment improved rhinorrea, instead both treatment didn't affect nasal congestion. CONCLUSIONS: According to the results of our multicentric double blind randomized study, we suggest the use of glucan solution nasal spray as an efficacious therapeutic tool in the management of nasal symptoms in patients affected by chronic rhinosinusitis.

Treatment of recurrent epistaxis in HHT.

No optimal treatment modality is currently available for the treatment of recurrent epistaxis in HHT. In this review, different therapeutic concepts are discussed together with their pathophysiologic background. Patients often profess a preventive effect for nasal ointments and use packings which can be self-administered in the case of bleeding. An effective first-line treatment for physicians is the endonasal laser coagulation or argon plasma coagulation. A second line surgical procedure is septodermoplasty according to Saunders which can provide long-lasting relief if performed correctly. There have been reports on antifibrinolytic agents and hormones, but their efficacy has yet to be determined.

Acoustic analysis of voice in patients treated by reconstructive subtotal laryngectomy. Evaluation and critical review.

Aim of this investigation was to analyse the voice in a group of 20 patients submitted to supracricoid partial laryngectomy (cricohyoidopexy, sparing two arytenoids) by the Multi Dimensional Voice Programme acoustic analysis system. Results revealed the following sound characteristics: high rate of noise, lack of periodic component of the signal, high rate of segments with no sound signal, vocal segments with marked air-turbulent flow, variation amplitude and frequency coefficients doubled compared to normal values, average fundamental frequency, if present, extremely variable and unsteady. These results show that the phonatory ability of the residual larynx, due to the altered anatomo-physiology of the structure after surgery, has to be completely re-estimated. In fact, the residual larynx determines a definitely reduced periodic acoustic signal, rich in noise and which can not be modulated. Good phonatory results of this treatment are basically due to preservation of a still understandable (but not perfect!) speech which, by ensuring the subjects' speech ability, overcomes and has little influence on the really poor quality of the vocal signal in these patients. However, the patient obtains a "new voice" as far as concerns acoustic features and this is very important for communication and social life. Moreover, the possibility of objectively estimating acoustic vocal function ability allows monitoring of the trend and results of possible speech therapy and/or phonosurgical rehabilitation treatment which should start from new anatomical and physiological bases, as well as from the new physical acoustic mechanism of signal production.

"Conditional" neck dissection in management of laryngeal carcinoma.

It is well known that malignant laryngeal tumours can extend from their site of origin into tributary lymph nodes, depending on their location and size. Management protocols almost always include concomitant surgical treatment of both the tumour and cervical nodes. When palpable lymph nodes are present, dissection is mandatory but there is no general agreement on the option of choice in clinically N0 patients. Elective neck dissection, following the current indications, is necessary in most cases of N0 laryngeal cancer, but the number of bilateral dissections may be limited. In tumours of only one hemilarynx or extending slightly beyond it, metastatic involvement is more likely to be on the same side as the lesion although there is no absolute certainty that it will be. In these cases, and especially in supraglottic tumours, occult metastatic spread may also penetrate into the contralateral lymph nodes of the neck. The present report deals with the results of a surgical strategy to limit bilateral elective dissection, based on the following criteria. In supraglottic tumours of only one hemilarynx or extending slightly beyond it, the presence of ipsilateral node metastases is highly predictive of a concomitant involvement of the contralateral nodes. In these supraglottic tumours, only in cases with post-operative serial positive histology of the uni-ipsilateral dissected cervical lymph nodes, has contralateral elective neck dissection ("conditional dissection") been performed. "Conditional dissections" led to a reduction of approximately 70% of elective bilateral neck dissections.

Major salivary gland diseases. Multicentre study.

This multicentre study involved 28 Italian ORL Centres responding to a questionnaire sent by us which allowed recruitment of a high large number of cases of parotid neoplasms observed over a 10-year period. Statistical data obtained partly confirmed previous findings. Benign tumours account for 80% of case histories with a relationship 1:4 M/F, the most frequent being pleomorphic adenoma (57.3% of cases), followed by Warthin's tumour (32.4%), this rating not having been confirmed in case histories (8-10%) in the literature. Malignant tumours instead were fewer in number compared to the literature (14% vs 25-30%); the most frequent being mucoepidermoid carcinoma (18.2%) of which 44% G1, 33% G2 and 23% G3. Adenoid-cystic carcinoma was observed in 15.3% and < or = 10% for all the other most frequent histological malignant neoplasms. Diagnostic work-up included echotomography and fine-needle aspiration biopsy, less used imaging techniques were computed tomography, magnetic resonance imaging, Sialo-computed tomography. During this multicentre investigation more widespread use of imaging techniques has, however, been observed. The greater use of ecotomography and of fine-needle aspiration biopsy was due to simplicity of application and low cost offering good sensitivity and specificity. Surgical treatment of benign tumours consisted, in 50% of cases, in superficial paroditectomy and in approximately 30% of total paroditectomy. Enucleoresection was limited to approximately 15% of neoplasms, enucleation to <10% of cases with only 2% of pleomorph adenoma due to the well-known anatomo-pathological characteristics which may lead to relapse. For malignant neoplasms, total parotidectomy was performed in approximately 50% of cases, while in the remaining 50% an almost equal rate of superficial parotidectomy was carried out and enlarged parotidectomy, with or without sacrificing the facial nerve, which was rebuilt in 60% of cases. The lateral neck dissection most frequently carried out was of functional type in 54% and selective type in 46% with removal of levels I-III and II-IV in approximately 60% of cases. Sentinel lymph node was observed in a limited number of centres. When no clinically evident lymph nodes were present (NO) considering the tumour histotype, two thirds of patients underwent surgery or radiotherapy, while in the remainder the wait-and-see attitude was prefered. Post-operative-complementary radiotherapy was very frequently performed instead of chemotherapy. Oncological results obtained were compared with those reported in the literature: in fact for all benign neoplasms relapse ratings are about 5%, while for malignant tumours the worst prognosis was in squamous cell carcinoma with median of 37.7 on survival and metastasis rate of 16.5%. Finally, mucoepidermoid carcinoma tumours showed best survival, followed by adenoid-cystic carcinoma with ranges, respectively, 83 and 81.

Pleurodesis by autologous blood, doxycycline, and talc in a rabbit model.

BACKGROUND: Management of recurrent spontaneous pneumothorax or symptomatic pleural effusion often uses thoracoscopic pleurodesis, about which many questions remain. Both effectiveness and toxicity of agents currently used for pleurodesis were evaluated in a rabbit model. METHODS: Agents administered were autologous blood 1 mL/kg, talc slurry (70 mg x mL(-1) x kg(-1)), and doxycycline 10 mg/mL, given through a chest tube to 30 rabbits. Controls had only chest tubes inserted. At 30 days surfaces were graded by gross observation and histologic examination. Blood and lung tissue from all animals were analyzed for enzymes and blood chemistries. RESULTS: Gross observations showed mediastinal thickening and adhesions with doxycycline, and threadlike adhesions with talc. Autologous blood was only slightly more effective than a chest tube alone. Talc significantly increased angiotensin converting enzyme activity in serum, whereas doxycycline changed liver function enzymes and produced tissue toxicity. CONCLUSIONS: Doxycycline produced effective pleurodesis but yielded remarkably severe local effects. The distant sequelae of talc and doxycycline pleurodesis-histologic changes in the contralateral lung and serum enzyme elevations-suggests undesirable systemic effects for the commonly used agents, and autologous blood exhibited no significant pleurodesis, short-term. The search for the ideal agent for chemical pleurodesis continues.

Characteristics of salivary diffuse infiltrative lymphocytosis syndrome in West Africa.

OBJECTIVE: To determine the prevalence of diffuse infiltrative lymphocytosis syndrome (DILS) in the minor salivary glands of 30 African Cameroonian adults with the acquired immunodeficiency syndrome (AIDS). DESIGN: Salivary gland tissue was analyzed using a modified classification system that was developed to aid the diagnosis of Sjögren syndrome. The advantages and disadvantages of this approach are discussed. MATERIALS AND METHODS: Formalin-fixed, paraffin-embedded, hematoxylin-eosin-stained biopsy sections were prepared for 30 patients with AIDS, 26 healthy individuals who declined human immunodeficiency virus (HIV) testing, and 4 seronegative healthy controls. Tissues were immunostained for CD4/CD8+ lymphocytes and cytomegalovirus (CMV), and transmission electron microscopy was performed to locate viral particles. Patients were tested for HIV-1 and HIV-2 by the HIV/Chek System 3 or CAMSTIX-HIV-1 and HIV-2 assay. RESULTS: Severe salivary ductal atypia (96%) was the feature most strongly associated with AIDS, and the lymphocytic focus score was the second histologic feature most strongly correlated with AIDS. Forty-eight percent of patients with HIV-1 infection had more than 1 lymphocytic focus in a minor salivary gland. These lymphocytes were primarily CD8+. We report, to the best of our knowledge, the first case of multinucleated salivary duct epithelial cells in minor salivary glands also containing enveloped virus particles. All cases were negative for CMV. CONCLUSIONS: The prevalence of DILS in West Africans with AIDS appears higher than the prevalence reported in whites from the United States and Europe and in blacks from the United States, a group that has been reported to have a greater incidence of DILS than whites. This discrepancy may be related to differences in patient selection criteria. The determination of lymphocytic focus score, as used in the diagnosis of Sjögren syndrome, with the adjunct of ductal atypia is useful for assessing DILS. The impact of patient selection, drug therapy, and parasites on salivary gland pathology is discussed.

Clear cell carcinoma of the palate.

A case of minor salivary gland clear cell adenocarcinoma of the palate with metastasis to the lungs in a 53-year-old female is presented. Histologically, the cells were characterized by glycogen rich clear cells arranged in solid nests, trabeculae, surrounded by hyalinized fibrous stroma. We believe this represents an aggressive form of this type of tumor.

Cytologic distinction between bronchioalveolar carcinoma and reactive/reparative respiratory epithelium: a cytomorphometric analysis.

Cytologically, the distinction between bronchioalveolar carcinoma and reactive/reparative processes of respiratory epithelium can be difficult. Retrospectively, we have identified 11 consecutive cases of bronchioalveolar carcinoma from the cytology files of University Missouri-Kansas City/Truman Medical Center. On average, a combined 5.71 cytologic/histologic procedures were performed before reaching a definitive diagnosis for this group. An additional seven random cases of reactive/reparative respiratory cases of adult respiratory distress syndrome patients were used as a control. Cytomorphometric analysis was performed. The mean average nuclear diameter for the carcinoma group was 13.76 microns and for the reactive/reparative group was 13.29 microns. There was no statistical difference between the two groups (paired student t test, P > .05). It appears from our data that mean nuclear diameter is not a discriminator for the cytologic distinction between bronchioalveolar carcinoma and reactive/reparative respiratory epithelium and that the accepted cytologic parameters of for bronchioalveolar carcinoma are more valid.

Artifactual endocervical atypia induced by endocervical brush collection.

The cytologic distinctions between artifactual atypia induced by endocervical brush collection, endocervical glandular repair, and endocervical glandular dysplasia or neoplasia are often difficult. This difficulty is amplified by the lack of accepted cytologic criteria for endocervical glandular dysplasia, and the fact that earlier studies defining the significant cytologic features of endocervical adenocarcinoma in situ and endocervical adenocarcinoma (endocervical neoplasia) utilized a swab for endocervical cell retrieval. With the almost universal adoption of the endocervical brush, it is important to redefine those cytologic characteristics that differentiate true endocervical glandular dysplasia or neoplasia from reactive or reparative processes and instrument artifact. From our data, it appears that the classically described cytologic discriminators between a negative smear and smears of endocervical dysplasia or neoplasia are basically unchanged with some minor modifications for endocervical brush-collected samples.

Multinodular goiter of the thyroid mimicking malignancy: diagnostic pitfalls in fine-needle aspiration biopsy.

A case of multinodular goiter with multicentric papillary hyperplasia is presented with cytologic features suggestive of thyroid papillary carcinoma. While the cytologic criteria for papillary thyroid carcinoma is well defined, occasional diagnostic difficulties can arise. Cytologically, the presence of focal papillary aggregates, the presence of a psammoma body within a background of copious colloid and scattered follicular cells led to diagnostic confusion. Histologically, the presence of secondary follicles in the papillae and protrusion of the papillary structures into colloid lakes supported the diagnosis of goiter. It is our opinion that most, if not all, of these difficulties can be circumvented by the incorporation of all major and some minor cytologic criteria for papillary carcinoma in the analysis of such lesions. Single criteria for papillary carcinoma, either major or minor, is not sufficient.

Fine-needle aspiration of well differentiated small-cell duct carcinoma of the breast.

Historically, fine-needle aspiration of the female breast has been accepted as a useful modality in the diagnosis of ductal as well as other types of breast carcinoma. However, cases of well differentiated small-cell duct carcinoma can be problematic. The differential diagnoses include fibrocystic disease, papillary neoplasia, fibroadenoma, and lobular carcinoma. Retrospectively, 16 cases of well differentiated small-cell duct carcinoma have been identified in the case files of Truman Medical Center/University of Missouri-Kansas City. Patient's ages ranged from 29-81 yr, with the mean being 56.2 yr. The overall cytologic features consisted predominantly of a hypercellular specimen with cohesive and rarely discohesive cells with no demonstrable nuclear atypia. For well differentiated small-cell duct carcinoma, the mean nuclear diameter was greater than that of a red cell (6-8 microns). For the well differentiated small-cell duct carcinoma group, the mean nuclear diameter was 9.86 microns; for fibrocystic disease, 12.86 microns; for papillomas, 8.28 microns; for fibroadenomas, 9.48 microns; and for lobular carcinoma, 11.88 microns. From our data, it appears that specific attention to the clinical presentation, cytologic pattern, and nuclear diameters are useful discriminators for well differentiated small-cell duct carcinoma.

Malignant thymoma in a patient with HIV positivity: a case report with a review of the differential cytologic diagnoses.

A 33-yr-old African-American male with known human immunodeficiency virus (HIV) positivity underwent CT guided fine-needle aspiration biopsy of an anterior mediastinal mass. The aspirate was composed of a dimorphic population of cells that included small mature lymphoid cells and scattered cohesive groups of large epithelial cells in equal numbers. The neoplasm stained strongly for low weight molecular cytokeratin, epithelial membrane antigen (EMA), leukocyte common antigen (LCA), and Leu-7 which was consistent with a diagnosis of thymoma. Subsequent biopsies determined the neoplasm to be a malignant (invasive) thymoma. This case emphasizes the efficacy of FNA biopsy for the evaluation of anterior mediastinal masses in HIV infected individuals. Additionally, the differential cytologic diagnoses for HIV infected individuals for this anatomic site are discussed.

Papanicolaou smears in pregnancy. Positivity of exfoliated cells for human chorionic gonadotropin and human placental lactogen.

Trophoblastic cells are seen rarely in cervical exfoliative cytology during normal pregnancy but are thought to occur with increasing frequency in the clinical setting of threatened abortion. We performed a clinicopathologic and immunologic study to determine the significance of multinucleate syncytiotrophoblastic and cytotrophoblastic cells in cervicovaginal smears from 13 women identified by cytomorphologic screening during a six-year period. Control groups included 11 patients who subsequently had spontaneous abortions and 15 patients with uneventful pregnancies. Immunocytochemistry was performed using a cocktail of antihuman chorionic gonadotropin and antihuman placental lactogen antisera. Five of the 13 screen-positive cases, 1 of the 11 spontaneous abortion cases and 0 of the 15 normal pregnancies were positive on immunostaining. Clinical follow-up showed that none of the screen-positive pregnancies, including those also positive on immunostaining, ended in spontaneous abortion. Further, there was no significant difference in fetal weight or Apgar scores between the controls and the screen-positive group. The presence of trophoblastic cells on cervicovaginal smears during pregnancy is not a reliable indicator of impending abortion.

AgNOR counts as a discriminator of lesions of the endocervix.

Recently the argyrophil for staining proteins associated with nucleolar organizing regions (AgNORs) has been applied widely in cytohistopathology in various malignancies. Nucleolar organizer region-associated proteins (NORs) are located on the short arm of chromosomes 13, 14, 15, 21 and 22. We applied the technique to 78 cytologic smears from the endocervix stained with the Papanicolaou technique. These included 36 normal endocervical cases, 17 reactive endocervical cases, 19 dysplastic endocervical cases and 6 endocervical adenocarcinoma cases. Statistically significant differences were found between AgNOR counts from normal endocervical smears and smears of endocervical gland dysplasia (P < .001), between normal endocervical smears and smears of endocervical adenocarcinoma (P < .001), between reactive endocervical smears and smears of endocervical gland dysplasia (P < .001) and between reactive endocervical smears and endocervical adenocarcinoma (P < .005). The AgNOR technique appears useful as an adjunct in the diagnosis of endocervical lesions.

Adenoid tissue rhinopharyngeal obstruction grading based on fiberendoscopic findings: a novel approach to therapeutic management.

OBJECTIVE: A grading into four classes of hypertrophied adenoid rhinopharyngeal obstructions in children on the basis of fiberendoscopic findings to outline an effective therapeutic program according to this classification. METHODS: Ninety-eight children with chronic nasal obstruction and oral respiration were examined by anterior rhinoscopy, and fiberendoscopy. During the investigation, the fiberendoscopic images of the choanal openings were divided into four segments from the upper choanal border to the nasal floor. In view of clinical findings, 78 patients also underwent active anterior rhinomanometry. RESULTS: In eight patients (8.2%), the fiberendoscopic imaging revealed that the adenoid tissue occupied only the upper segment in the rhinopharyngeal cavity (< 25%). Therefore, choanal openings were free (first degree obstructions). In 20 patients (20.4%), the adenoid tissue was confined to the upper half (< 50%) of the rhinopharyngeal cavity (second degree obstructions) and in 63 patients (64.3%) the tissue extended over the rhinopharynx (< 75%) with obstruction of choanal openings and partial closure of tube ostium (third degree obstructions). Only in seven cases (7.14%), the obstruction was almost total. As a consequence, both the tube ostium and the lower choanal border could not be observed (fourth degree obstructions). CONCLUSIONS: In the first two classes of obstructions, characterized by moderate or discrete adenoid hypertrophy, adenoidectomy should not be performed. In these conditions, the causes of possible nasal obstructions are usually due to either dysmorphic, allergic or phlogistic pathologies. For the fourth degree adenoid obstructions, surgery is always recommended. The most important therapeutic problems occur in the third degree obstructions which include most patients who suffered from hypertrophied adenoids. Moreover, the therapeutic strategy can be conditioned not only by nasal respiratory difficulties but also by frequent concomitant complications such as otitis, sinusitis, sleep apnea, etc. These disorders may be caused by both nasal obstruction and/or phlogistic problems (adenoiditis).