Usefulness of N-vinyl-2-pyrrolidone Embalming for Endoscopic Transnasal Skull Base Approach in Cadaver Dissection

Formalin or formaldehyde is commonly used for cadaver fixation, which is, however, not suitable for endoscopic transnasal skull base approach because of consequent hardening of the soft tissue. Several alternatives have been reported, but each of them also has some limitations. We applied a novel fixation method using N-vinyl-2-pyrrolidone (NVP), a precursor of the water-soluble macromolecular polymer, for endoscopic transnasal skull base approach in six donated cadaver specimens. In four cadavers, elasticity of the soft tissue in the nasal cavity was almost similar to that of living tissue, and a surgical approach similar to the real surgical field was possible. However, the soft tissue was moderately stiffer than living tissue in two specimens so that surgical manipulation was hindered to some extent while NVP concentration was 10% in all the cadavers. Since the brain tissue was too soft and pliable for surgical manipulation in NVP, more careful surgical manipulation than real surgical field was mandatory in order to prevent damage in the brain tissue. Therefore, this concentration of NVP was considered to be appropriate. In conclusion, NVP embalming was effective for endoscopic transnasal skull base approach in cadaver dissection, providing environment similar to the real surgical field.

Clinical Significance of Tumor-Related Edema of Optic Tract Affecting Visual Function in Patients with Sellar and Suprasellar Tumors

OBJECTIVE

Preoperative tumor-related edema of the optic tract (EOT) is often found along the white matter tract of the visual system. However, the relationship of EOT with visual function and outcome remains unclear. Therefore we aimed to elucidate whether the presence of EOT is associated with visual outcome in patients with sellar and suprasellar tumors.

METHODS

A total of 212 eyes of 106 patients who underwent endoscopic endonasal surgery for sellar and suprasellar tumors at our institution between March 2016 and August 2018 were included in this retrospective study. Data on patient characteristics, preoperative magnetic resonance imaging findings, and ophthalmologic evaluations were collected. Patients were assigned to 2 groups depending on preoperative magnetic resonance imaging findings (EOT group = 19 [17.9%], non-EOT group = 87 [82.1%]). Visual acuity, visual field (VF), global visual function score, VF index, VF mean deviation, and retinal nerve fiber layer thickness as determined by optical coherence tomography were compared between the groups before and after treatment.

RESULTS

In the EOT group, 4 patients had pituitary adenoma, 8 had craniopharyngioma, and 7 had other pathologies. There was no significant difference of pathologies between the groups. Preoperatively, EOT group showed significantly lower values of global visual function score, VF index, mean deviation, and retinal nerve fiber layer thickness than did the non-EOT group (P < 0.001). Postoperatively, the EOT group showed worse visual outcomes than did the non-EOT group.

CONCLUSIONS

This study reveals that EOT caused by sellar and suprasellar tumors is associated with worse visual function and poor improvement postoperatively.

Ultrafine particle deposition in a realistic human airway at multiple inhalation scenarios

The scarcity of regional deposition data in distal respiratory airways represents an important challenge for current toxicology and pharmacology research. To bridge this gap, a realistic airway model extending from nasal and oral openings to distal bronchial airways with varying pathway length was built in this study. Transport and deposition characteristics of naturally inhaled ultrafine particles (UFPs) ranging from 1 to 100 nm were numerically investigated, and effects of different inhalation scenarios were considered. To enable intercase particle deposition comparison, an adjusted parameter, unified deposition enhancement factor (UDEF), was proposed for quantifying the localised deposition concentration. Results show that compartment particle deposition peaked around the ultrafine end of the considered size range, and it dropped rapidly with the increase of particle size. Different inhalation modes caused notable deposition changes in the extrathoracic region, while its effects in the TB airway are much less. For UFPs larger than 10 nm, predicted deposition efficiencies in all compartments are all at lowest levels among considered particle size range, implying UFPs ranging from 10 to 100 nm can travel through the whole respiratory airway model and escape to the alveolar region. Furthermore, high enhancement factors were observed at the vicinity of most bifurcation apexes, and more even UDEF distribution was observed from 1-nm particle cases. While for 100-nm cases, the deposited particles tend to concentrate at few "hot spots" (areas of high deposition concentration in relation to surrounding surfaces) with greater UDEF in the tracheobronchial airway.

[Negative effects of stripe conchotomy on intranasal conditioning]

OBJECTIVE

Partial resection of the caudal part of the inferior turbinate including the head is still performed in rhinosurgery ("stripe conchotomy"). However, extensive resections of the turbinate affect nasal airflow and intranasal conditioning. The aim of this study was to determine the effect of partial resection of the inferior turbinate including its head on intranasal air flow as well as warming and humidification of the inspired air by means of computational fluid dynamics.

MATERIALS AND METHODS

A bilateral, realistic nasal model was created based on the CT scan of a patient. A unilateral partial resection of the lower turbinate on the right side had been performed externally. A numerical simulation was performed to analyze intranasal air flow patterns, temperature, and humidity distribution of the inspired air.

RESULTS

Due to the partial resection of the lower turbinate on the right side, the flow pattern was significantly altered compared to the opposite side. Resection leads to a centered and higher velocity in the inferior nasal meatus as well as to reduced heating and humidification of the inhaled air compared to the untouched left nasal cavity.

CONCLUSION

Partial resection of the caudal part of the inferior turbinate may lead to disturbed intranasal conditioning of inspired air if performed too radically. Therefore, if possible, this procedure should be avoided and a more gentle mucosal procedure chosen.

[Infantile hemangiopericytoma of the nasal cavity]

An infantile sinunasal hemangiopericytoma as a variant of infantile myofibroma is a rare finding. The observation of a sinunasal, infantile hemangiopericytoma affecting the anterior skull base and ethmoid bone in a female infant is presented. Chromosomal gains (6q14q16.2 und 18q22qter) as well as chromosomal losses (5q33.3q35.2, 10p11.2p12.2, 10q24.3q26.1, 15q23q25, 17p12pter and 22q11.2q13.2) were present. Endonasal tumor resection was achieved.

Correlation between Temporomandibular Joints and Nasal Cavity Width in Growing Patients after Rapid Maxillary Expansion

AIM

The study tests the correlation between the enlargement of the nasal cavity width, interglenoid fossa distance, and intercondylar distance after rapid maxillary expansion (RME) in growing patients.

MATERIALS AND METHODS

Cone beam computed tomography (CBCT) was performed for 25 patients presenting a bilateral crossbite (11 males, 14 females, and mean age 11.6 ± 1.6 years) at baseline (T0) and at 6 months after RME (T2), T1 being the end of expander activation. Images were digitized for linear measurements using specific software. Values were compared at the nasal width, interglenoid fossa distance, and intercondylar distance to test the correlation in the transverse dimension.

RESULTS

At T0, a correlation already existing between the interglenoid fossa distance and the intercondylar distance persisted at T2. The correlation between the nasal cavity width and interglenoid fossa distance nonexistent at T0 ended toward statistically significant at T2. Additionally, the lateral position of the condyles was not correlated with the nasal cavity width neither at T0 or T2.

CONCLUSION

A correlation between the interglenoid fossa distance and intercondylar distance was exhibited 6 months after RME. The correlation between the nasal cavity width and interglenoid fossa distance was close to significant at T2.

Isolated primary maxillary sinus esthesioneuroblastoma presenting as idiopathic syndrome of inappropriate antidiuretic hormone

Esthesioneuroblastoma is an uncommon tumour, and isolated primary involvement of the maxillary sinus is exceedingly rare. Esthesioneuroblastoma has infrequently been reported as a source of paraneoplastic ectopic hormone production. We report a case of isolated primary maxillary esthesioneuroblastoma, presenting as idiopathic syndrome of inappropriate antidiuretic hormone (SIADH). A 17-year-old girl presented with symptoms consistent with SIADH and no sino-nasal symptoms. MRI to exclude pituitary tumour revealed an isolated lesion of the right maxillary sinus. Biopsy demonstrated esthesioneuroblastoma. The lesion was removed endoscopically as a single en bloc specimen. Following resection, the sodium level returned to normal. This is only the third report in the literature of a primary maxillary esthesioneuroblastoma presenting as SIADH.

Fate of the inhaled smoke particles from fire scenes in the nasal airway of a realistic firefighter: A simulation study

Understanding the inhalation, transport and deposition of smoke particles during fire missions are important to evaluating the health risks for firefighters. In this study, measurements from Underwriters Laboratories' large-scale fire experiments on smoke particle size distribution and concentration in three residential fire scenes were incorporated into models to investigate the fate of inhaled toxic ultrafine particulates in a realistic firefighter nasal cavity model. Deposition equations were developed, and the actual particle dosimetry (in mass, number and surface area) was evaluated. A strong monotonic growth of nasal airway dosages of simulated smoke particles was identified for airflow rates and fire duration across all simulated residential fire scene conditions. Even though the "number" dosage of arsenic in the limited ventilation living room fire was similar to the "number" dosage of chromium in the living room, particle mass and surface area dosages simulated in the limited living room were 90-200 fold higher than that in the ventilated living room. These were also confirmed when comparing the dosimetry in the living room and the kitchen. This phenomenon implied that particles with larger size were the dominant factors in mass and surface area dosages. Firefighters should not remove the self-contained breathing apparatus (SCBA) during fire suppression and overhaul operations, especially in smoldering fires with limited ventilation.

Assessment of respiratory muscle strength and airflow before and after microimplant-assisted rapid palatal expansion

OBJECTIVES

To assess alterations in respiratory muscle strength and inspiratory and expiratory peak flow, as well as skeletal and dental changes in patients diagnosed with transverse maxillary deficiency before and after microimplant-assisted rapid maxillary expansion (MARPE).

MATERIALS AND METHODS

Twenty patients (13 female and 7 male) were assessed by respiratory tests in three different periods: T0 initial, T1 immediately after expansion, and T2 after 5 months. Tests included: maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP), oral expiratory peak flow, and inspiratory nasal flow. Cone-beam computed tomography measurements were performed in the maxillary arch, nasal cavity, and airway before and immediately after expansion.

RESULTS

There was a significant increase in MIP between T0 and T2 and MEP between T0 and T1 (P<.05). Oral and nasal peak flow increased immediately after and 5 months later, especially in patients with initial signs of airway obstruction (P<.05). In addition, after expansion there was a significant enlargement of the nasal cavity, alveolar bone, and interdental widths at the premolar and molar region. Molars tipped buccally (P<.05) but no difference was found in premolar inclination. MARPE increased airway volume significantly.

CONCLUSIONS

Skeletal changes promoted by MARPE directly affected airway volume, resulting in a significant improvement in muscle strength and nasal and oral peak flow.

Feasibility of transnasal flexible carbon dioxide laser surgery for laryngopharyngeal lesions

OBJECTIVE

The fiber-guided carbon dioxide (CO₂) laser is a useful device for laryngopharyngeal surgery. The flexible CO₂ wave-guide laser has been developed and commercially available for several years. However, the transnasal use of CO₂ flexible wave-guided laser surgery through the instrument channel of a flexible endoscope (CO₂ TNFLS) is not permitted in Japan. This feasibility study aimed to assess the value and the safety of an in-office CO₂ TNFLS procedure.

METHODS

Patients with small laryngopharyngeal diseases were enrolled from June 2015. Eligible patients had indications with lesions generally localized superficial lesions such as the benign tumor, leukoplakia, and premalignant lesion-like carcinoma in situ (CIS). Patients were locally well anesthetized using xylocaine. After removing as much of the lesion(s) as possible with flexible forceps, the remainder of the lesions were evaporated using CO₂ TNFLS through the instrument channel of a flexible endoscope under local anesthesia.

RESULTS

Eighteen surgeries involving 13 patients, including 9 papilloma (7 recurrent respiratory papilloma [RRP]), 2 carcinoma in situ, 1 leukoplakia, and 1 large epiglottic cyst), were performed. Four patients with RRP required multiple surgeries. Except for 3 patients with RRP, all patients achieved disease control without additional intervention. All procedures were completed with no severe adverse events.

CONCLUSION

Office-based CO₂ TNFLS is safe and feasible for patients with laryngopharyngeal pathologies. It is especially valuable for RRP patients with small lesions to avoid surgery under general anesthesia.

Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review

OBJECTIVE

This systematic review aims to determine the effects of non-surgical rapid maxillary expansion (RME) on breathing and upper airway structures.

MATERIALS AND METHODS

An electronic search of the scientific literature from January 2005 to June 2016 was done using Web of Science, Dentistry & Oral Sciences Source and PubMed databases. A combination of search terms "rapid maxillary expansion", "nasal", "airway" and "breathing" were used. Studies that involved surgical or combined RME-surgical treatments and patients with craniofacial anomalies were excluded.

RESULTS

The initial screening yielded a total of 183 articles. After evaluation of the titles, abstracts and accessing the full text, a total of 20 articles fulfilled both inclusion/exclusion criteria and possessed adequate evidence to be incorporated into this review.

CONCLUSIONS

Non-surgical RME was found to improve breathing, increase nasal cavity geometry and decrease nasal airway resistance in children and adolescents.

Respiratory epithelial adenomatoid hamartoma - typical but underdiagnosed pathology of nasal cavity and sinuses

Respiratory epithelial adenomatoid hamartoma (REAH) is relatively new diagnosis, firstly described in WHO tumour classification in 2005. It is a benign lesion affecting nose and paranasal sinuses. Although REAH was considered a rare entity, it is recently more frequently revealed in histopathological exam in patients undergoing endoscopic surgery for nasal polyposis. There have been so far operated two patients with diagnosis of REAH in our department. Both were solitary lesions, and both were resected endoscopically. Definitive histopathological examination confirmed the finding of preoperative biopsy under local anesthesia. No recurrent disease has been observed. Considering quite frequent occurrence of REAH in patients with nasal polyposis and low awareness of the disease itself among ENT specialists, pathologists and radiologists it is still relatively underdiagnosed lesion. The possibility of misdiagnosis and confusion with other more serious diseases like inverted papilloma or low-grade adenocarcinoma is of clinical importance. It may lead to overtreatment and too aggressive surgical therapy.

Malignant peripheral nerve sheath tumor of the nasal cavity and nasopharynx in a child: A case report

RATIONALE

Malignant peripheral nerve sheath tumors (MPNSTs) are rare neoplasms with only a few reported cases affecting the nasal cavity, paranasal sinuses, and anterior skull base.

PATIENT CONCERNS

A 12-year-old girl with a mass in her nose was admitted to the Department of Otorhinolaryngology of Shenzhen Children's Hospital. She had a 4-month history of progressive, unilateral right nasal obstruction, unilateral mucopurulent rhinorrhea, foul nasal odor, snoring, hyposmia, occasional epistaxis, and no headache, no facial numbness, without eye swelling and vision loss.

DIAGNOSE

A computed tomography (CT) scan of the paranasal sinuses showed a mass (right inflammatory polyp and calcification) involving the nasal cavity, the right maxillary sinusitis, ethmoid sinusitis. There was no nasal septum, orbital, or skull base involvement. On the basis of pathological and immunohistological findings, the tumor was diagnosed as an MPNST with heterogeneous components (cartilage and bone) mesenchymal differentiation after the operation.

INTERVENTIONS

The girl was treated by surgery and chemotherapy.

OUTCOMES

The postoperative course was uneventful. There was no recurrence observed during the 3-year follow-up.

LESSONS

The primary MPNST in the nasal cavity is rare, if nasal neoplasms do not respond well to vasoconstrictors and glucocorticoids in children, the possibility of a tumor should be considered. If new organisms grow rapidly with hemorrhagic necrosis, the possibility of a malignant tumor is greater.

DEVELOPMENT OF THE INNER NASAL CAVITY IN ANIMALS IN PHYLO- AND ONTOGENESIS: FUNCTIONAL ANATOMIC SIGNIFICANCE IN THE DEVELOPMENT PERIOD ROZWÓJ WEWNĘTRZNEJ JAMY NOSOWEJ U ZWIERZĄT W FILO- I ONTOGENEZIE: CZYNNOŚCIOWE I ANATOMICZNE ZNACZENIE W OKRESIE ROZWOJOWYM

OBJECTIVE

Іntroduction: Main functions of the inner nose in humans are respiration and olfaction. Therefore, human needs a large surface of inhalable and exhalable air contact, warming and moistening. Importance of these organs in animals in phylogenesis before and after the secondary palate development can explain their anatomic and functional designation. The aim is to find out the functional significance of some anatomic formations of the inner nose and their development peculiarities in phylo-and ontogenesis.

PATIENTS AND METHODS

Materials and methods: We used a comparative anatomy method where we compared well-known facts of different animals' development before and after secondary palate formation in phylo- and ontogenesis.

RESULTS

Review: Olfactory organ in lower vertebrates develops as canal with two openings through which as a result of water penetration the olfactory ability increases. Sinuses formation in animals happens after secondary palate formation. Secondary palate in embryo develops by second month of development, and sinuses' development begins on the 3-4 month. As a result, upper jaws and facial skull became stronger. Importance of mucous and lacrimal glands of the nose cavity and mucous glands of mouth received new functions of animal and vegetable food digestion.

CONCLUSION

Conclusions: development of the secondary palate in warm-blooded vertebrates changed (limited) functional applicability of the lacrimal gland and nasolacrimal canal, mucous glands of nose and vegetative innervation. Groups of lacrimal, mucous glands of nose and mouth are unified system of primary, neurosecretory reaction to environment.

Parechovirus and enterovirus infections in neonates

BACKGROUND

Parechovirus and enterovirus belong to a family of Picornaviridae, non- enveloped, small-sized RNA viruses, responsible for multiple human diseases. Recent introduction of molecular tests enabled the identi cation of parechovirus and enterovirus infections. Our aim was a retrospective analysis of signs and symptoms associated with confirmed parechovirus or enterovirus infections among children treated in the Department of Neonatology, St. Louis Regional Children's Hospital in Kraków, Poland.

METHODS

Based on laboratory records, we identified all cases of parecho- or enterovirus infections confirmed by identification of viral RNA in nasal swab or cerebrospinal fluid samples. Hospital records and laboratory tests results of selected patients were then analyzed, and selected data were summarized, with emphasis on clinical and laboratory findings at admission.

RESULTS

We identified 11 cases of parechovirus and three of enterovirus infections. All cases were neonates admitted to hospital with fever and irritability. Except for leukopenia in 50% of patients, no significant abnormalities were noted in blood counts and serum biochemistry, including low C-reactive protein and procalcitonin. In nine cases, cerebrospinal fluid was collected, the fluid protein concentrations and cell counts were moderately increased. Final diagnosis was meningitis in 12 children, and other viral infections in two.

CONCLUSIONS

Viral infection, including parecho- and enteroviruses, should be considered in the etiology of fever and meningitis in neonates. The available molecular tests allow for detection of viral genetic material even in a scant biological specimen collected from neonates.

New insertion method of transnasal ileus tube for small bowel obstruction: Anterior balloon method

Background

Small bowel obstruction (SBO) is usually caused by postoperative adhesions and malignant disease, and decompression is effective for SBO. Our previous case report suggested that a new transnasal ileus tube insertion method, the anterior balloon method (ABM), could achieve decompression for adhesive SBO.

Aims

The study aimed to investigate the effectiveness of a new method for inserting transnasal ileus tubes in patients with SBO.

Methods

Altogether, 134 patients with small bowel obstruction treated from January 2011 to December 2017 were reviewed. The patients were categorized into two groups: those with the new method that inserts an anterior balloon (ABM group: 52 patients, 2014–2017) versus those with the ordinary insertion method (OIM group: 82 patients, 2011–2014).

Results

The patients’ characteristics and symptoms on admission were similar in the ABM and OIM groups. Adhesions were the main cause of ileus in the two groups. The insertion time duration was significantly shorter in the ABM group than in OIM group (28.4 ± 9.1 vs. 33.5 ± 13.0 min; p = 0.01). The ABM group also had significantly longer tubes than OIM group (222.4 ± 32.2 vs. 157.4 ± 31.7 cm; p < 0.001), which resulted in a significantly shorter time until clinical symptoms were relieved in ABM group. There were no significant differences in adverse events between the two groups.

Conclusions

The ABM group had shorter insertion duration and longer tubes than those of OIM group. The ABM might become a preferred therapeutic choice to achieve decompression in patients with SBO.

Pattern Of Presentation Of Nasal Foreign Bodies, An Experience With 155 Patients

BACKGROUND

Children commonly present to outpatient department with foreign bodies in the nose. Sometimes the history is straightforward but not infrequently presentation is with a foul-smelling unilateral discharge and obstruction. Most of the foreign bodies are inert and do not cause any local tissue reaction but some of these can cause serious complications. The frequency of the different types of foreign bodies is not known in our setup. Our study aims to determine the types and frequencies of different foreign bodies in our catchment area so as to make the attending surgeon aware of the different possibilities he may have to encounter. Also, we aimed to make the general public aware of the hazards which the foreign bodies can create.

METHODS

This descriptive cross-sectional study was carried out at Department of ENT of Ayub Teaching Hospital Abbottabad, from 1st June to 30th November 2017. During the period of study, patients presenting in outpatient department with nasal foreign bodies were included in the study. We recorded patients' age and gender. Types of foreign bodies recovered from the nose were documented and their frequency was calculated.

RESULTS

A total of 155 patients were included in the study. 60% of the foreign objects were inserted in the nasal passage by male children. Children below the age of 4 years comprised more than 55% of the cases. Mean age 4.5±2.36 years. Right nostril was predominantly involved (58%). Various seeds were commonly retrieved (40%). Plastic beads were the second most common foreign bodies (21.2%). Other foreign bodies found were buttons (9%), dry batteries (1.2%), stones (9%), toy pieces (4.5%), and food particles (10%).

CONCLUSIONS

The commonest nasal foreign objects in children were organic seeds followed by plastic beads.

Intralacrimal migration of Masterka® stents

BACKGROUND

Tearing and conjunctivitis in children are commonly due to lacrimal drainage system obstruction. Congenital nasolacrimal obstruction is a common pathology treated by probing with or without silicone stent insertion, depending upon the age of the child. The silicone stent is self-retaining and placed for at least one month. Masterka^® is a recent version of Monoka^®, which may lead to the same surgical complications, such as intralacrimal migration.

SUBJECTS AND METHODS

The medical records of two patients surgically treated with the Masterka^® probe for nasolacrimal duct obstruction, who developed intralacrimal migration of the stent, were retrospectively reviewed and analyzed. A 41-month-old child and an 18-month-old child presented with disappearance of the silicone tube after 7 days and 2 years respectively. In the first case, the tube migrated completely within the lacrimal system and became externalized through the nose at 2 years, while in the second case, the Masterka^® was retrieved through a canalicular approach. In both cases, infants had no further tearing.

DISCUSSION

The frequency self-retaining stent disappearance is estimated at 15%. Among these cases, intralacrimal migration is only reported in 0.5% of cases. To prevent intralacrimal migration, the surgical technique must follow a certain number of rules. Management, based on residual epiphora, is discussed.

CONCLUSION

Prevention of intralacrimal migration of self-retaining stents involves a rigorous analysis of the relationship between the meatus and the fixation head at the time of placement. After lacrimal intubation, scheduled monitoring is necessary to screen for stent disappearance. Management is based on clinical findings, anterior rhinoscopy and even exploratory canaliculotomy.

Comprehensive molecular profiling of advanced/metastatic olfactory neuroblastomas

Olfactory neuroblastoma (ONB) is a rare, locally aggressive, malignant neoplasm originating in the olfactory epithelium in the nasal vault. The recurrence rate of ONB remains high and there are no specific treatment guidelines for recurrent/metastatic ONBs. This study retrospectively evaluated 23 ONB samples profiled at Caris Life Sciences (Phoenix, Arizona) using DNA sequencing (Sanger/NGS [Illumina], n = 15) and gene fusions (Archer FusionPlex, n = 6), whole genome RNA microarray (HumanHT-12 v4 beadChip, Illumina, n = 4), gene copy number assays (chromogenic and fluorescent in situ hybridization), and immunohistochemistry. Mutations were detected in 63% ONBs including TP53, CTNNB1, EGFR, APC, cKIT, cMET, PDGFRA, CDH1, FH, and SMAD4 genes. Twenty-one genes were over-expressed and 19 genes under-expressed by microarray assay. Some of the upregulated genes included CD24, SCG2, and IGFBP-2. None of the cases harbored copy number variations of EGFR, HER2 and cMET genes, and no gene fusions were identified. Multiple protein biomarkers of potential response or resistance to classic chemotherapy drugs were identified, such as low ERCC1 [cisplatin sensitivity in 10/12], high TOPO1 [irinotecan sensitivity in 12/19], high TUBB3 [vincristine resistance in 13/14], and high MRP1 [multidrug resistance in 6/6 cases]. None of the cases (0/10) were positive for PD-L1 in tumor cells. Overexpression of pNTRK was observed in 67% (4/6) of the cases without underlying genetic alterations. Molecular alterations detected in our study (e.g., Wnt and cKIT/PDGFRA pathways) are potentially treatable using novel therapeutic approaches. Identified protein biomarkers of response or resistance to classic chemotherapy could be useful in optimizing existing chemotherapy treatment(s) in ONBs.

Alternate-Nostril Yoga Breathing Reduced Blood Pressure While Increasing Performance in a Vigilance Test

BACKGROUND Reports suggest that vigilance or sustained attention increases sympathetic activity. A persistent increase in sympathetic activity can lead to an increase in blood pressure. Alternate-nostril yoga breathing has been shown to be useful to (i) improve attention and (ii) decrease the systolic and diastolic blood pressure. Earlier studies did not report simultaneous recordings of the blood pressure and performance in vigilance tests after alternate-nostril yoga breathing. With this background, the present study was planned to determine if 15 minutes of alternate nostril yoga breathing could improve the performance in a vigilance test without an increase in blood pressure. MATERIAL AND METHODS Fifteen healthy male volunteers participated in the study (group mean age ±SD, 22.4±2.4 years). Participants were assessed on 3 separate days in 3 different sessions. These were (i) alternate nostril yoga breathing, (ii) breath awareness, and (iii) sitting quietly as a control. Blood pressure and the digit vigilance test were simultaneously assessed before and after each session. RESULTS Systolic blood pressure (p<0.01), mean arterial blood pressure (p<0.05), and the time taken to complete the digit vigilance test (p<0.05) significantly decreased following alternate-nostril yoga breathing. The time taken to complete the digit vigilance test differed significantly between sessions (p<0.05). The time taken to complete the digit vigilance test was also significantly decreased after sitting quietly (p<0.01). CONCLUSIONS Alternate-nostril yoga breathing appears to improve performance in the digit vigilance test, along with a reduction in systolic blood pressure. This is suggestive of better vigilance without sympathetic activation.

Influence of Altered Auditory Feedback on Oral-Nasal Balance in Speech

PURPOSE

This study explored the role of auditory feedback in the regulation of oral-nasal balance in speech.

METHOD

Twenty typical female speakers wore a Nasometer 6450 (KayPentax) headset and headphones while continuously repeating a sentence with oral and nasal sounds. Oral-nasal balance was quantified with nasalance scores. The signals from 2 additional oral and nasal microphones were played back to the participants through the headphones. The relative loudness of the nasal channel in the mix was gradually changed so that the speakers heard themselves as more or less nasal. An additional amplitude control group of 9 female speakers completed the same task while hearing themselves louder or softer in the headphones.

RESULTS

A repeated-measures analysis of variance of the mean nasalance scores of the stimulus sentence at baseline, minimum, and maximum nasal feedback conditions demonstrated a significant effect of the nasal feedback condition. Post hoc analyses found that the mean nasalance scores were lowest for the maximum nasal feedback condition. The scores of the minimum nasal feedback condition were significantly higher than 2 of the 3 baseline feedback conditions. The amplitude control group did not show any effects of volume changes on nasalance scores.

CONCLUSIONS

Increased nasal feedback led to a compensatory adjustment in the opposite direction, confirming that oral-nasal balance is regulated by auditory feedback. However, a lack of nasal feedback did not lead to a consistent compensatory response of similar magnitude.

Transnasal Snare Technique for Retrograde Primary Jejunostomy Placement After Surgical Gastrojejunostomy

PURPOSE

To report a transnasal snare technique for retrograde primary jejunostomy placement after surgical gastrojejunostomy.

MATERIALS AND METHODS

Two patients underwent the transnasal snare technique for retrograde primary jejunostomy placement. Patients included two females, age 58 and 62. In both patients, a gooseneck snare was inserted in a transnasal fashion. After insertion of the snare into the jejunum, the location was confirmed with ultrasound. The snare was then targeted using a Chiba needle through which a 0.018-inch wire was advanced and snared through the nose. The wire was exchanged for a 0.035-inch Amplatz wire over which the tract was serially dilated followed by insertion of the jejunostomy catheter through a peel-away sheath. Technical success, complications, and follow-up were recorded.

RESULTS

Primary jejunostomy placement was technically successful in both patients. No minor or major complications occurred. Both patients received enteral nutrition the day following placement. Follow-up was at 54 and 38 days for patients 1 and 2, respectively.

CONCLUSION

The transnasal snare technique provides a novel alternative for primary jejunostomy insertion allowing for targeting of the jejunum with improved procedural success and no complications.

Quantitative Comparison of Three Endoscopic Approaches to the Parasellar Region: Laboratory Investigation

BACKGROUND

Endoscopic endonasal transsphenoidal and contralateral sublabial transmaxillary approaches are used for approaching parasellar lesions. The aim of this anatomical study was to compare endoscopic endonasal uninostril and binostril (contralateral) and contralateral sublabial transmaxillary approaches via a quantitative analysis of exposure limits and instrument working avenues.

METHODS

Six formalin-fixed silicone-injected adult cadaveric heads (12 sides) were studied. The surgical working area, depth of the surgical corridor, angle of attack, and surgical freedom were measured and compared for the 3 approaches.

RESULTS

The endoscopic binostril endonasal approach to the parasellar area provided greater surgical freedom in the opticocarotid recess (OCR) and superior orbital fissure (SOF) compared with that of the uninostril endonasal approach (OCR, P < 0.01; SOF, P = 0.01) and the contralateral sublabial transmaxillary approach (OCR, P = 0.01; SOF, P = 0.03). The horizontal and vertical angles of attack with the binostril endonasal approach also were greater than those of the uninostril approach (OCR, P ≤ 0.05; SOF, P ≤ 0.01) and the contralateral transmaxillary approach (OCR, P ≤ 0.01; SOF, P ≤ 0.01). However, the contralateral sublabial transmaxillary approach provided more lateral exposure than the uninostril or binostril endonasal approach to the parasellar area, and it enabled a shorter surgical trajectory to the contralateral parasellar area (P < 0.01).

CONCLUSIONS

An anatomical comparison of the 3 endoscopic approaches to the parasellar area showed that the binostril approach provides greater exposure and freedom for instrument manipulation. The contralateral transmaxillary route provided a more lateral view, increasing exposure on average by 48%, with shorter surgical depth; however, surgical freedom was inferior to that of the binostril approach.

The immediate effect of facial candling on inflammatory mediators, substance P, symptoms severity, and quality of life in allergic rhinitis patients: Study protocol for a randomized controlled trial

INTRODUCTION

Asian countries have a variety of ethnic groups and culture that provide their own traditional treatment in health care. Facial candling appears to be one of the popular traditional treatments in Southeast Asian. The complementary medicine practitioners promote that the facial candling treatment would help in reducing the symptoms of allergic rhinitis and other problems related to sinus. Due to the lack of evidence available, the effectiveness of this treatment method and its mechanism, however, remains unknown. The objective of this research is therefore to study impact of facial candling on inflammatory mediators, substance P (SP), symptoms severity, and quality of life (QoL) in allergic rhinitis patients.

METHOD AND ANALYSIS

A randomized, nonblinded, controlled trial will be carried out by recruiting a total of 66 eligible allergic rhinitis patients who fulfill the inclusion criteria from a university health center. The subjects will be randomly assigned into 2 groups: intervention group receiving facial candling treatment and control group (no treatment given). Samples of blood and nasal mucus will be collected right before and after intervention. Samples collected will be analyzed. The primary outcomes are the changes in the level of SP in both blood and mucus samples between both groups. The secondary outcomes include the levels of inflammatory mediators (ie, tumor necrosis factor alpha, interleukin (IL)-3, IL-5, IL-6, IL-10, and IL-13) and the severity of allergic rhinitis symptoms as measured by a visual analogous scale and QoL using the Rhinitis Quality of Life Questionnaire (RQLQ).

ETHICAL AND TRIAL REGISTRATION

The study protocols are approved from the Ethical and Research Committee of the Universiti Teknologi MARA (REC/113/15). The trial is registered under the Australia New Zealand Clinical Trial Registry (ACTRN12616000299404). The trial was registered on 03/07/2016 and the first patient was enrolled on 10/12/2016.

CONCLUSION

Facial candling is one of the unique treatments using candles to reduce the severity of symptoms and inflammation. This is the first ever study conducted on facial candling that will give rise to new knowledge underlying the effects of facial candling on severity of symptoms and inflammation relief mechanism mediated by substance P and inflammatory mediators.

Mutation status among patients with sinonasal mucosal melanoma and its impact on survival

BACKGROUND

Sinonasal mucosal melanoma (SNMM) comprises <1% of all melanomas and lacks well-characterised molecular markers. Our aim was to determine the frequencies of common mutations and examine their utility as molecular markers in a large series of primary SNMMs.

METHODS

SNMM patients seen at our institution from August 1991 through July 2016 were identified. Genomic DNA was extracted from 66 formalin-fixed paraffin-embedded tumours and screened for mutations by direct sequencing. We investigated the association of mutations with clinicopathological features and survival outcomes.

RESULTS

Overall, 41% (27 out of 66) of the SNMMs harboured mutations. BRAF and KIT mutations were identified in 8% (five patients) and 5% (three patients) of SNMMs, respectively, whereas NRAS mutations were detected in 30% (20 patients) of SNMMs. Mutation rates in these oncogenes were similar between SNMMs located in the paranasal sinuses and those in the nasal cavity (30% and 13%, respectively, P=0.09). In a multivariate analysis, patients with negative margins had significantly better overall survival (hazard ratio 5.43, 95% confidence interval 1.44-21.85, P=0.01) and disease-specific survival (hazard ratio 21.9, 95% confidence interval 3.71-180, P=0.0004). The mutation status of the tumours showed no association with survival outcomes.

CONCLUSIONS

In SNNM, mutation status does not affect survival outcomes, but NRAS mutations are relatively frequent and could be targeted in this disease by MEK inhibitors.

[Numerical Investigation of Particle Deposition in Human Nasal Cavity for Different Parameters of Spay Device]

Whether the drug is successfully transported to the focus area is the key to the treatment of the rhinitis disease. The efficiency of drug delivery is dependent on the design of nasal spray device. A three-dimensional model of nasal cavity was constructed from the head CT image data of a healthy human subject. The deposition of drug particles was simulated numerically by Computational Fluid Dynamics technique. The main variables of the study were the size and density of drug particles, the injecting speed of drugs etc. In conclusion, with the increase of particle intensity and injection speed, the deposition of particles in the affected area trends to increase after first slow decrease.

An immobile postsurgical nasojejunal tube: a case for King Arthur!

A patient was referred to an Endoscopy Unit for removal of a nasojejunal feeding tube that was previously inserted one week before during gastric surgery. Upper endoscopy revealed the nasojejunal tube sutured to the gastric wall and it was then removed with hot biopsy forceps. This case represents an uncommon complication of gastric surgery and highlights that a nasojejunal feeding tube should only be positioned after the suturing procedures and the mobility of the tube should always be tested during surgery.

Sinonasal Small Round Blue Cell Tumors: An Immunohistochemical Approach

Although clinical history and morphologic appearance should be the initial considerations when evaluating small round blue cell tumors of the sinonasal tract, the final diagnosis often hinges on immunohistochemical findings. Unfortunately, interpretation of stains in these tumors is fraught with numerous pitfalls and limitations. This article presents an approach to sinonasal small round blue cell tumors based on four common immunohistochemical patterns: cytokeratin positivity, squamous marker positivity, neuroendocrine marker positivity, and cytokeratin negativity.

Haemangiopericytoma-like tumor of the nasal cavity treated by endoscopy - a case report

Haemangiopericytoma (HPC) is an uncommon, vascular tumor derived from Zimmerman pericytes surrounding blood vessels. HPC constitute around 1% of all tumors of vascular origin and may appear anywhere, 5% of them can be situated in nasal cavity. Tumor location within the head and neck predispose to its benign character and improves prognosis. This case report presents the case of 33-year-old patient with haemangiopericytoma-like tumor of the nasal cavity, presented symptoms of impaired nasal breathing and recurrent epistaxis. Tumor was excised with 0 degree endoscope. The follow-up recurrence-free period was 2 year 6 months and shows this is effective way of treatment. Described in the literature late recurrences and metastases reminds that regular, life-long observation is mandatory.

[Localized Amyloidosis Involving the Nasal Cavity]

BACKGROUND

Amyloidosis is a disease characterized by deposits of abnormal protein known as amyloid in various organs and tissues. It can be classified into systemic or localized forms, the latter of which is less frequent. Deposition of amyloidogenic monoclonal light chains leads to the most common type of this disease called light-chain (AL) amyloidosis. (18)F-FDG positron emission tomography/ computed tomography hybrid imaging (FDG-PET/ CT) demonstrates tracer uptake usually in all patients with localized amyloidosis as opposed to the systemic form.

CASE

Herein, we present a case of an otherwise healthy 56-year-old women diagnosed with a nasal polyp on the right side. The biopsy results were consistent with amyloidosis. FDG-PET/ CT imaging revealed a pathological, metabolically active lesion measuring 11 × 9 mm with a maximum standardized uptake value (SUV(max)) of 3.47. No other distant pathological changes were identified. After a radical resection, the patient has been regularly followed-up with clinical and imaging methods (MRI, FDG-PET/ CT), both of which repeatedly showed normal findings with disease-free survival of 27 months. Thus, FDG-PET/ CT imaging plays an important role not only for obtaining the right diagnosis but also in the follow-up of patients after surgical resection. In accordance with the literature, this case report confirms that FDG-PET/ CT imaging holds promise as an auxiliary method for distinguishing between localized and systemic forms of amyloidosis.

Pedunculated carcinoma ex pleomorphic adenoma of the nasal cavity: A unique case report

BACKGROUND

A carcinoma ex pleomorphic adenoma (CXPA) is an epithelial malignancy arising in or from a benign pleomorphic salivary adenoma. The parotid gland is the most common location of CXPAs. Minor salivary gland CXPAs of the nasal cavity are exceedingly rare, with only 6 documented in the literature.

METHODS AND RESULT

We present a 7th case: an unusual pedunculated intranasal CXPA, which had a favorable outcome after a wide endoscopic excision and the longest follow-up period reported to date. The clinical features, immunohistochemical characteristics, treatment choices, and disease outcomes of the intranasal CXPAs reported in previous studies are also reviewed.

CONCLUSION

This case demonstrates the importance of considering the possibility of CXPA in the differential diagnosis of minor salivary gland malignancies in the nasal cavity.

[Nasal cavity and paranasal sinus cancer]

The nasal cavity and parasinusal cancer are rare (10% of tumors of the head and neck) and are mainly represented by squamous cell carcinoma of the nasal cavity or the maxillary sinus and adenocarcinoma of the ethmoid sinus (occupational disease, wood dust). The most common clinical sign is nasal obstruction, but tumors can also manifest as rhinorrhea and/or epistaxis (usually unilateral signs). A magnetic resonance imaging of the facial structure is systematic for staging before treatment. The treatment consists of a first surgery if the patient is operable with a resectable tumor. If it is not the case, the treatment consists of radiotherapy (RT) associated with chemotherapy (CT) according to the initial data (T3/T4 or N+). After first surgery, RT is indicated (except T1N0 with complete resection) associated with a CT based on postoperative data (capsular effraction or incomplete resection). Lymph node irradiation is considered case by case, but is indicated in any nodal involvement. RT must be an intensity modulated RT (IMRT), static or dynamic, and must be imagery guided (IGRT). According to ICRU 83, doses to organs at risk and target volumes must be carried. Finally, after a post-treatment baseline imaging between 2 and 4 months, monitoring will be alternated with the ENT surgeon every 2 or 3 months for 2 years, then every 4 to 6 months for 5 years.

Short-term and long-term test-retest reliability of the Nasality Severity Index 2.0

PURPOSE

The Nasality Severity Index 2.0 (NSI 2.0) forms a new, multiparametric approach in the assessment of hypernasality. To enable clinical implementation of this index, the short- and long-term test-retest reliability of this index was explored.

METHODS

In 40 normal-speaking adults (mean age 32y, SD 11, 18-56y) and 29 normal-speaking children (mean age 8y, SD 2, 4-12y), the acoustic parameters included in the NSI 2.0 (i.e. nasalance of the vowel /u/ and an oral text, and the voice low tone to high tone ratio (VLHR) of the vowel /i/) were obtained twice at the same test moment and during a second assessment two weeks later. After determination of the NSI 2.0, a comprehensive set of statistical measures was applied to determine its reliability.

RESULTS

Long-term variability of the NSI 2.0 and its parameters was slightly higher compared to the short-term variability, both in adults and in children. Overall, a difference of 2.82 for adults and 2.68 for children between the results of two consecutive measurements can be interpreted as a genuine change. With an ICC of 0.84 in adults and 0.77 in children, the NSI 2.0 additionally shows an excellent relative consistency. No statistically significant difference was withheld in the reliability of test-retest measurements between adults and children.

CONCLUSION

Reliable test-retest measurements of the NSI 2.0 can be performed. Consequently, the NSI 2.0 can be applied in clinical practice, in which successive NSI 2.0 scores can be reliably compared and interpreted.

LEARNING OUTCOMES

The reader will be able to describe and discuss both the short-term and long-term test-retest reliability of the Nasality Severity Index 2.0, a new multiparametric approach to hypernasality, and its parameters. Based on this information, the NSI 2.0 can be applied in clinical practice, in which successive NSI 2.0 scores, e.g. before and after surgery or speech therapy, can be compared and interpreted.

The relationship between the Nasality Severity Index 2.0 and perceptual judgments of hypernasality

PURPOSE

The Nasality Severity Index 2.0 (NSI 2.0) forms a new, multiparametric approach in the identification of hypernasality. The present study aimed to investigate the correlation between the NSI 2.0 scores and the perceptual assessment of hypernasality.

METHOD

Speech samples of 35 patients, representing a range of nasality from normal to severely hypernasal, were rated by four expert speech-language pathologists using visual analogue scaling (VAS) judging the degree of hypernasality, audible nasal airflow (ANA) and speech intelligibility. Inter- and intra-listener reliability was verified using intraclass correlation coefficients. Correlations between NSI 2.0 scores and its parameters (i.e. nasalance score of an oral text and vowel /u/, voice low tone to high tone ratio of the vowel /i/) and the degree of hypernasality were determined using Pearson correlation coefficients. Multiple linear regression analysis was used to investigate the possible influence of ANA and speech intelligibility on the NSI 2.0 scores.

RESULTS

Overall good to excellent inter- and intra-listener reliability was found for the perceptual ratings. A moderate, but significant negative correlation between NSI 2.0 scores and perceived hypernasality (r=-0.64) was found, in which a more negative NSI 2.0 score indicates the presence of more severe hypernasality. No significant influence of ANA or intelligibility on the NSI 2.0 was observed based on the regression analysis.

CONCLUSION

Because the NSI 2.0 correlates significantly with perceived hypernasality, it provides an easy-to-interpret severity score of hypernasality which will facilitate the evaluation of therapy outcomes, communication to the patient and other clinicians, and decisions for treatment planning, based on a multiparametric approach. However, research is still necessary to further explore the instrumental correlates of perceived hypernasality.

LEARNING OUTCOMES

The reader will be able to (1) describe and discuss current issues and influencing variables regarding perceptual ratings of hypernasality; (2) describe and discuss the relationship between the Nasality Severity Index 2.0, a new multiparametric approach to hypernasality, and perceptual judgments of hypernasality based on visual analogue scale ratings; (3) compare these results with the correlations based on a single parameter approach and (4) describe and discuss the possible influence of audible nasal airflow and speech intelligibility on the NSI 2.0 scores.

Retinal Branch Artery Embolization Following Hyaluronic Acid Injection: A Case Report

Injection of hyaluronic acid (HA) filler is a common aesthetic procedure. Impairment of vision, although rare, is a devastating complication of this procedure, which may not be reversible. We report on a patient who experienced visual acuity impairment and ischemic oculomotor nerve palsy after injection of HA into the nasal dorsum. In this case, clinical signs improved within 14 days of treatment. We also provide a review of the mechanism, clinical features, risk factors, and prevention and treatment strategies relating to embolization of ocular circulation after injection of HA. Vision loss is a rare but devastating complication of injection of hyaluronic acid (HA) in the face. Visual acuity seldom recovers completely. We report on a 22-year-old Asian woman who experienced obstruction of a branch of the retinal artery after injection of HA to augment her nose. The patient's visual acuity declined shortly after the procedure, and ophthalmoplegia occurred. Combination treatment was administered to restore the perfusion and oxygen supply to the retina and optic nerve. Within 14 days of rigorous treatment, the patient experienced improvement in visual acuity, extraocular movement, and visual field defects. LEVEL OF EVIDENCE 5: Risk.

Patterns of regional and distant metastasis in esthesioneuroblastoma

OBJECTIVES/HYPOTHESIS

To define the incidence and risk factors of metastatic disease and the effectiveness of salvage therapy in esthesioneuroblastoma (ENB).

STUDY DESIGN

Retrospective analysis of 57 patients presenting from 1979 through 2009.

METHODS

Cumulative incidence of neck failure, distant failure, and survival were assessed using the Kaplan-Meier method.

RESULTS

Overall survival for all patients was 85% at 5 years and 75% at 10 years. Overall survival was negatively impacted by intracranial tumor extension (P < 0.001), positive resection margins (P = 0.05), and neck metastases (P = 0.017). Neck lymph nodes were not routinely electively irradiated during this time period. Nodal metastases developed in 17% of patients at a median time of 60 months. Kadish stage was not associated with a risk of nodal metastasis (P = 0.78). After treatment for nodal recurrence, locoregional control was achieved in 78% of patients. Of patients developing nodal recurrence, more than half developed distant metastases. The cumulative incidence of distant metastasis was 39% at a median time of 40 months. Patients who presented with Kadish stage C or D had a significantly increased risk of distant failure (P < 0.001). In patients developing nodal (P = 0.017) or distant metastasis (P = 0.001), the probability of survival was significantly decreased.

CONCLUSION

Regional and distant metastases in patients with esthesioneuroblastoma occur in a delayed fashion and negatively impact survival. Neck nodal recurrence may be a harbinger of distant metastases. At the Memorial Sloan Kettering Cancer Center, New York, New York, we now treat the majority of ENB patients with elective nodal irradiation. However, the chief obstacle to long-term cure is distant metastases.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1556-1561, 2016.

Standardization procedure for the nasal nitric oxide measurement method using Niox MINO® and the tidal-breathing technique with velum-closure

Nitric oxide (NO) is a molecule that performs many functions in the human body. The entire respiratory tract can produce NO, but the highest production occurs in the upper respiratory tract, in the paranasal sinuses in particular. The aim of the present study was to assess a new nasal NO (nNO) measurement method using the Niox MINO Nasal® device (Aerocrine AB, Solna, Sweden) and a special procedure, in order to compare the nNO values obtained in 32 healthy subjects with the values found in the international literature. The measured normal nNO values were equal to 426.76±143.27 ppb, with a 95% confidence interval [160.22-733.30]. Males had an average nNO value equal to 446.76±133.63 [178.64 – 714.02], whereas in females the average value was 403.80±154.90 [94.00-713.60]. This study allows us to confirm that we have been able to establish the normal range of nitric oxide quantity produced in the nasal/sinus cavities of healthy individuals using the Niox MINO Nasal® device and tidal-breathing with velum-closure manoeuvre.

Sinonasal angioleiomyoma

BACKGROUND

Angioleiomyoma of the nasal cavity is an extremely rare benign neoplasm. It usually occurs in the lower extremities. Up to date, only few cases of angioleiomyoma have been reported. First case of angioleiomyoma of nasal cavity was reported in 1966. We report a rare case of angioleiomyoma arising from the right maxillary sinus.

CASE REPORT

A 43-year-old lady presented with recurrent epistaxis and right nasal obstruction for two months duration. Clinical examination revealed a huge right nasal mass obstructing the right nasal cavity. The tumour was excised completely via endoscopic endonasal surgical approach. Histopathological examination confirmed the tumour is sinonasal angioleiomyoma. Postoperatively, she recovered well without any recurrence after a year of followup.

CONCLUSION

This tumour has an excellent prognosis and recurrence is extremely rare if excised completely.

Combined modality therapy of esthesioneuroblastoma

Objective

Esthesioneuroblastoma (ENB) is a rare tumor of the olfactory epithelium. The objective of this study was to evaluate treatment modalities including surgery, IMRT, and chemotherapy and patient outcomes.

Patients and Methods

A retrospective analysis was performed on a total of 21 patients. Therapy included craniofacial resection (CFR), radiotherapy, chemotherapy, or a combination of these methods.

Results

The median follow-up period was 47 months. Surgery was performed in 90.4% of cases; radiotherapy was performed adjuvantly in 15 (72.7%) patients. Surgery, radiotherapy, and chemotherapy were administered to 7 (33.3%) patients. Eight (38.3%) patients had local recurrence. The 5-year crude overall survival was 71.4% and actuarial 5-year overall survival was 58% with confidence interval (CI, 25 and 81, respectively). The 5-year crude disease-free survival rate was 59% and the 5-year actuarial disease-free survival rate was 62% (CI, 28 and 83, respectively).

Conclusion

Multidisciplinary therapy of ENB should be considered, especially for Kadish C and high-grade lesions. Craniofacial resection (CFR), Intensity modulated radiation therapy (IMRT), and chemotherapy should be investigated in a multi-institution trial of ENB. © 2007 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.