Oncological Outcomes of Transoral Laryngeal Microsurgery with Fiber-Optic Diode Laser for Early Glottic Cancer: A Single-Center Experience

Backgroud/Objectives: Transoral laser laryngeal microsurgery (LTLM) has been widely used in the treatment of early-stage glottic laryngeal squamous cell carcinoma (LSCC) for the past few decades. Although T stage, tumor grade, anterior commissure involvement, type of cordectomy, positive surgical margin, and postoperative additional therapies were accused as the prognostic factors for recurrence, there is still controversy about these data in the literature. The purpose of this study was to evaluate the oncological results of our patients with early glottic LSCC treated with LTLM as a single-modality therapy in a single-center study.

METHODS

Patients with early-stage (Tis-1-2/N0) glottic LSCC who underwent LTLM as a primary treatment from 2011 to 2019 were retrospectively reviewed. The clinicopathological factors and oncologic outcomes were analyzed.

RESULTS

One hundred and sixty-one patients were enrolled in this study. The 5-year overall (OS), disease-specific (DSS), disease-free (DFS), and laryngectomy-free survival rates were 84.5%, 97.9%, 79.2%, and 93.5%, respectively. The most common stage, histopathological type, and type of endoscopic cordectomy were T1 stage, well-differentiated cancer, and type 2 cordectomy, respectively. A positive surgical margin was defined in 20 (12.4%) patients. There was a significant relationship between histopathological grade and positive surgical margins (p = 0.038). OS and DSS rates of "wait and see" modality were lower, while DFS of radiotherapy was lower than that of other treatment modalities in patients with positive surgical margins, but the differences were not statistically significant. Nineteen (11.8%) patients had a recurrence. DSS was statistically significantly lower in patients with recurrence (p < 0.001).

CONCLUSION

The results of our study showed that anterior commissure involvement, surgical margin positivity, and higher T stage statistically did not reduce survival rates in early-stage LSCC patients treated with LTLM. As the histopathological grade of the tumor worsens, the risk of surgical margin positivity increases. RT may have a negative effect on recurrence and organ preservation in the additional treatment of patient with positive surgical margins.

How important is the Sphenoseptal cell in identifying the skull base? Recent incidence and demonstration of endoscopic surgical steps

Background/aim

Because of close relations to important anatomical structures such as cavernous sinus and optic nerve, sphenoid sinus variations must be well trained by the otolaryngologist who has an interest in endoscopic sinus surgery. Newly defined sphenoseptal cell (SSC) is one of those variations that may lead to insufficient endoscopic sinus surgery outcomes if not defined preoperatively with imaging studies. The present study aimed to present the main characteristics of this special type of nasal cell.

Materials and methods

In this study, 610 paranasal sinus CT scans were analyzed and reviewed retrospectively between May 2018 and December 2019. Also, endoscopic findings of SSC that cause a surgical catastrophe in identifying skull base and sella are presented during transnasal transsphenoidal pituitary surgery.

Results

According to its definition and relation to the sphenoid sinus and the skull base, an SSC was seen in 21 scans of 610 patients (3.4%), 11 were women (55%) and 10 were men (45%).

Conclusion

Although an SSC is a rare variation of nasal air cells, preoperative diagnosis of this cell is of paramount importance in some patients during endoscopic transnasal surgery for the identification of skull base.

Impact of fetal brain tissue derived mesenchymal stem cell and fibrin glue on facial nerve crash injury

Background/aim

To evaluate the clinical and histopathological effects of fetal brain tissue derived mesenchymal stem cells (FBTMSC) and fibrin glue (FG) on the facial nerve (FN) regeneration in rats with traumatic FN injury.

Materials and methods

Twenty-eight Sprague Dawley rats were included in the study and divided into 4 groups. Traumatic FN injury (FP) was created by a surgical clamp compression to the main trunk of left FN in all groups. In the control group (group 1) no treatment was applied, in group 2 (FBTMSC group) 2 × 106 FBTMSC was injected, in group 3 (FG group) only FG was applied, in group 4 (FBTMSC and FG groups) both FBTMSC and FG were applied to the injured section of the nerve. The FN functions were evaluated clinically, immediately after the procedure and at 3rd, 5th, and 8th weeks postoperatively. The FNs of all subjects were excised after the 8th week; then the rats were sacrificed. The presence of stem cells in the injured zone was assessed using bromo-deoxyuridine (BrdU), and apoptosis was determined by the TUNEL method.

Results

After the damage, total FP was observed in all subjects. Statistically significant functional improvement was observed in group 4 compared to all other groups (P < 0.005). TUNEL-positive cell count was statistically significantly higher in the control group than the other groups (P < 0.001). TUNEL-positive cell count was statistically significantly lower in group 4 than the other groups. The proportion of BrdU-stained cells in group 4 (5%) was higher than group 2 (2%).

Conclusion

Clinically and histopathologically FBTMSC applied with FG may play a promising role as a regenerative treatment in posttraumatic FP.

Is There Any Effect of Subjective Tinnitus on Vestibular Evoked Myogenic Potentials

Idiopathic subjective tinnitus has a complex pathophysiology in which not only cochlear and central classical auditory pathways but also nonclassical auditory pathways of different parts of the brain are involved. Vestibuloocular and vestibulocollic pathways are the central projections of utricle and saccule used in the vestibular evoked myogenic potential (VEMP) test. Aim of this study was to investigate the effects of idiopathic subjective tinnitus on vestibuloocular and vestibulocollic pathways via VEMP. We prospectively analyzed 30 unilateral idiopathic subjective tinnitus patient's cervical, ocular VEMP tests, tinnitus handicap index scores, symptom duration and compared with contralateral ear and 35 healthy volunteers. The latencies and amplitudes of P1 and N1 waves were recorded and pathologic wave criteria was calculated according to healthy volunteer's data. In cervical VEMP there were significant longer latencies of P1 and N1 waves with respect to contralateral ear and control group. In ocular VEMP test, N1 and P1 latencies and amplitudes were not significantly different. The percentages of pathologic wave of the tinnitus side were not significantly higher in both cervical VEMP and ocular VEMP tests with respect to contralateral side. Tinnitus handicap index scores and symptom duration had no relationship with latency and amplitude of VEMP tests. Although cervical VEMP P1 and N1 latencies were significantly longer, subjective tinnitus did not result in pathological alterations in the VEMP test. Presence of subjective tinnitus is not an influencing factor in the VEMP interpretation.

"In-Office Balloon Sinus Ostial Dilation with Concurrent Antiplatelet and Anticoagulant Therapy for Chronic Rhinosinusitis without Nasal Polyps"

OBJECTIVE

Functional endoscopic sinus surgery (FESS) and balloon sinus ostial dilation (BSD) are well-recognized minimally invasive surgical treatments for chronic rhinosinusitis without nasal polyps (CRSsNP) refractory symptoms to medical therapy. Patients on antiplatelet and anticoagulant therapies (AAT) usually are recommended to discontinue their medications around the period of endoscopic sinus surgery. The goal of this study is to assess the clinical experience of BSD in CRSsNP patients with concurrent anticoagulant or antiplatelet therapy.

METHODS

A review of prospectively-collected clinical data from October 2012 to March 2017 were used to perform a cohort study of subjects with CRSsNP who met criteria for surgical intervention while on antiplatelet and anticoagulant therapy. Data were collected on demographics, details of the procedures, type of AAT used, pre- and postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores, and complications.

RESULTS

Thirty-five patients underwent in-office BSD while on antiplatelet and/or anticoagulant therapy. The mean difference in pre- and postoperative SNOT-22 scores of 9.9 (SD 14.4, P < .001) was both statistically significant and exceeded the minimal clinically important difference of 8.9. Absorbable nasal packing was used for persistent bleeding immediately post-procedure in two patients. Intraoperative bleeding was associated with aspirin 325 mg and warfarin. FESS was required for further management of chronic sinusitis in four patients after anticoagulant/antiplatelet therapy could be discontinued. There were no systemic complications. None of the patients experienced significant bleeding events postoperatively after leaving the office.

CONCLUSION

In-office BSD appears to be a safe alternative to endoscopic sinus surgery in select patients who cannot discontinue antiplatelet and anticoagulant therapy.

LEVELS OF EVIDENCE

IV.

Evaluation of Voice Quality in Patients With Vocal Fold Polyps: The Size of a Polyp Matters or Does it?

OBJECTIVE

This study aimed to investigate the correlation between morphological features of vocal fold polyps (VFPs) and subjective/objective voice parameters.

METHODS

Perceptual evaluations, aerodynamic and acoustic tests were performed on 47 patients with VFPs. Still images were captured from video and the morphological features associated with the size of VFP were quantified. To reveal the correlation between size-related morphological features (length of polyp base, the ratio of polyp base to vocal fold length, glottal gap area) and objective/subjective parameters of voice, Pearson's and Spearman's tests were carried out.

RESULTS

This cohort was composed of 30 (63.8 %) male and 17 (36.2%) female patients with the mean age of 45.2 years and 41.3 years, respectively. No correlation was found between the morphological features of VFPs and any of perceptual, aerodynamic and acoustic voice parameters.

CONCLUSIONS

Our findings indicated that controversies still exist regarding the role of vocal fold polyp morphology in clinical decision making.

The Malignancy Risk Assessment of Cytologically Indeterminate Thyroid Nodules Improves Markedly by Using a Predictive Model

OBJECTIVES

The majority of thyroid nodules are discovered incidentally, and the management may be a challenge if the fine needle aspiration specimen yields indeterminate findings. Our aim was to develop an individualized risk prediction model to provide an accurate estimate of cancer risk in patients with cytologically indeterminate thyroid nodules.

MATERIALS AND METHODS

Clinical records, ultrasound images, and cytopathology reports of patients who underwent thyroidectomy were retrospectively reviewed. Logistic regression analysis was used to identify the predictive ability of each variable for malignancy, and a nomogram was built by integrating patients' age, multiplicity of nodules, cytology results, and suspicious ultrasound features, such as microcalcifications and irregular margins.

RESULTS

For the 233 indeterminate nodules according to the Bethesda System for Reporting Thyroid Cytopathology, the malignancy rates of the subgroups "atypia of undetermined significance," "suspicious follicular neoplasia," and "suspicious for malignancy" were 44.3, 47.7, and 88.0%, respectively. It was found that the Bethesda category "suspicious for malignancy," microcalcifications, and irregular margins were independent risk factors for malignancy. The area under the receiver operating characteristics curve was 0.784, which suggested that the presented nomogram had considerable discriminative performance.

CONCLUSIONS

The nomogram developed in our study accurately predicts the malignancy risk of thyroid nodules with indeterminate cytology by using clinical, cytological, and ultrasonographic features.

Glottic airway gain after 'suture arytenoid laterofixation' in bilateral vocal cord paralysis

CONCLUSION

This method is an easy, non-expensive, and effective technique in bilateral vocal cord paralysis to improve glottic airway and clinical performance.

OBJECTIVE

To evaluate the effectiveness of 'suture arytenoid laterofixation' surgery in bilateral vocal cord paralysis.

MATERIALS AND METHODS

A retrospective analysis of patients' medical history undergoing 'suture arytenoid laterofixation' surgery for bilateral vocal cord paralysis. This technique was applied under general anesthesia with both microlaryngoscopy and video-monitoring. Two 16 g needles and one 1/0 nylon thread were used for the procedure with 1 cm skin incision; no tracheotomy or tissue excision was required. Pre-post-operative photographs of the glottic region were taken from the endoscopic records, and the areas of rima glottis openings were calculated with the Image-J programme.

RESULTS

Forty-seven patients were analyzed. The mean pre-post-operative rima glottis areas were 1.11 ± 0.56 and 2.24 ± 0.93 mm(2), respectively (p < 0.001). Five patients with previous tracheotomy were decannulated within a few days after the operation. In three patients, mild complications developed in the early post-operative period (two laryngeal edemas, one submucosal hematoma). Tracheotomy was performed to only one pregnant patient in the post-operative first day. None of the patients had granulation formation or synechia.

Prevalence of Biofilms and Their Response to Medical Treatment in Chronic Rhinosinusitis without Polyps

Objective. The aim of this study was to investigate the prevalence of biofilms and the effects of medical treatment modalities in chronic rhinosinusitis (CRS) patients without nasal polyps.

Study Design. Randomized controlled trial.

Settings. Tertiary referral hospital.

Subjects and Methods. The authors randomly divided 32 adult patients with CRS without nasal polyps into 2 groups. In the first group (n = 16), oral clarithromycin was administered 500 mg/bid for 2 weeks and then 250 mg/d for the following 6 weeks. In the second group (n = 16), an 8-week course of 200-mcg/d topical mometasone furoate was added to the clarithromycin regimen, identical to the first group. The pre- and posttreatment nasal tissue samples were evaluated by scanning electron microscopy for biofilm prevalence and graded from 0 to 3 according to density and extension.

Results. Biofilms were detected in 24 of 32 patients (75%) before the treatment (grades 1-3). Biofilms were detected in 14 of 32 patients (43.8%) after the treatment (grades 1-2). When each group was evaluated independently, there was a significant improvement after the treatment in both groups I and II. When the biofilm grades of group I were compared to those of group II, there was no significant difference both in the pre- and posttreatment evaluation.

Conclusion. The prevalence of biofilms in CRS without polyps was 75% in our study. Regression of biofilms to 43% was observed under medical treatment. Adding nasal steroids to macrolides gave no further benefit.