3D video-assisted trans-oral removal of deep hilo-parenchymal sub-mandibular stones

The aim of this paper is to describe the intra-operative findings and surgical results of the first application of 3D high-definition (HD) endoscopic support to the trans-oral surgical treatment of five patients with deep hilo-parenchymal sub-mandibular stones who underwent clinical and ultrasonographic (US) follow-up examinations at one month after the procedure. Five patients undergoing 2D-HD video-assisted transoral surgery for the same condition were used as controls. The results were classified as successful (US - demonstrated complete clearance) or unsuccessful (US - demonstrated total or partial persistence). Visual analogue scales (VAS) were used post-surgically to evaluate the sharpness and brightness of the 2D and 3D images on the screen and stereoscopic depth perception (SDP) of the 3D-HD endoscope. Successful stone removal and significant subjective improvement (lack of obstructive symptoms) was obtained in all but one of the patients in the 3D group, in whom the one-month US evaluation revealed a residual 3 mm asymptomatic hilo-parenchymal stone that was successfully treated by sialendoscopy-assisted intra-corporeal laser lithotripsy. Wharton’s duct and the lingual nerve were identified and preserved in all cases. The mean 3D-HD VAS results were brightness 7 (range 6-8), sharpness 7.8 (range 7-9) and SDP 8.2 (range 8-9); the mean 2D-HD results were brightness 7.8 (range 7-9) and sharpness 7 (range 7-8). Our findings confirm the safety and efficacy of conservative transoral surgical treatment of hilo-parenchymal sub-mandibular stones. From a surgeon’s perspective, 3D-HD guided exploration of the oral floor seems to provide a better view of Wharton’s duct and the lingual nerve, especially near the sub-mandibular parenchyma. The 3D-HD video-assisted transoral removal of deep hilo-parenchymal sub-mandibular stones can therefore be considered a useful new means of preserving the function of an obstructed salivary gland.

Interventional sialendoscopy for radioiodine-induced sialadenitis: quo vadis?

Salivary gland toxicity is a common adverse effect of radioactive iodine (¹³¹I) for the treatment of thyroid cancers with a prevalence ranging from 2% to 67% of the ¹³¹I exposed population. Recently, sialendoscopy has been introduced as an attractive diagnostic and therapeutic tool for management of patients with radioiodine-induced sialadenitis that is unresponsive to standard medical treatments. The objective of the current review was to assess the impact of this procedure on outcomes in patients suffering from radioiodine sialadenitis. Overall, eight studies were included and 122 patients underwent 264 sialendoscopic procedures. Duct stenosis and mucous plugs were observed in 85.7% of endoscopic findings, supporting the role of ductal obstruction in the pathophysiology of radioiodine sialadenitis. In total, 89.3% of patients experienced complete or partial resolution of sialadenitis recurrences without any major adverse events, and parotidectomy was advocated in only 1 case. However, outcomes mainly concerned subjective reports and only two clinical experiences evaluated objective measurement with dissimilar results. Limited to few studies, xerostomia and obstructive symptoms responded differently after sialendoscopy. The optimal timing of salivary gland videoendoscopy needs to be further analysed in order to define the best management of radioiodine-induced obstructive sialadenitis.

Modern management of paediatric obstructive salivary disorders: long-term clinical experience

Recent technological improvements in head and neck field have changed diagnostic and therapeutic strategies for salivary disorders. Diagnosis is now based on colour Doppler ultrasonography (US), magnetic resonance (MR) sialography and cone beam 3D computed tomography (CT), and extra- and intracorporeal lithotripsy, interventional sialendscopy and sialendoscopy-assisted surgery are used as minimally invasive, conservative procedures for functional preservation of the affected gland. We evaluated the results of our long-term experience in the management of paediatric obstructive salivary disorders. The study involved a consecutive series of 66 children (38 females) whose obstructive salivary symptoms caused by juvenile recurrent parotitis (JRP) (n = 32), stones (n = 20), ranula (n = 9) and ductal stenosis (n = 5). 45 patients underwent interventional sialendoscopy for JRP, stones and stenoses, 12 a cycle of extracorporeal shockwave lithotripsy (ESWL), three sialendoscopy-assisted transoral surgery, one drainage, six marsupialisation, and two suturing of a ranula. Three children underwent combined ESWL and interventional sialendoscopy, and seven a secondary procedure. An overall successful result was obtained in 90.9% of cases. None of the patients underwent traditional invasive sialadenectomy notwithstanding persistence of mild obstructive symptoms in six patients. No major complications were observed. Using a diagnostic work-up based on colour Doppler US, MR sialography and cone beam 3D TC, children with obstructive salivary disorders can be effectively treated in a modern minimally-invasive manner by extracorporeal and intracorporeal lithotripsy, interventional sialendoscopy and sialendoscopy-assisted transoral surgery; this approach guarantees a successful result in most patients, thus avoiding the need for invasive sialadenectomy while functionally preserving the gland.

Outcomes of interventional sialendoscopy for obstructive salivary gland disorders: an Italian multicentre study

Interventional sialendoscopy has become the predominant therapeutic procedure for the management of obstructive salivary disorders, but only a few multicentre studies of large series of patients with a long-term follow-up have been published. This Italian multicentre study involved 1152 patients (553 females; mean age 50 years) who, after at least a clinical and ultrasonographic evaluation, underwent a total of 1342 diagnostic and interventional sialendoscopies, 44.6% of which involved the parotid gland. 12% (n = 138) of patients underwent multiple treatments. The procedure was successful in 1309 cases. In 33 cases (2.4%) the procedure could not be concluded mainly because of complete duct stenosis (21 cases). Salivary stones were the main cause of obstruction (55%), followed by ductal stenosis and anomalies (16%), mucous plugs (14.5%) and sialodochitis (4.7%). Complete therapeutic success was obtained in 92.5% of patients after one or more procedures, and was ineffective in < 8%. Untoward effects (peri and postoperative complications) were observed in 5.4% of cases. Sialendoscopy proved to be an effective, valid and safe procedure in the diagnostic and therapeutic management of non-neoplastic obstructive salivary gland diseases.

MR Imaging in Sudden Sensorineural Hearing Loss. Time to Talk

Sudden sensorineural hearing loss is defined as acute hearing loss of the sensorineural type of at least 30 dB over 3 contiguous frequencies that occurs within a 72-hour period. Although many different causative factors have been proposed, sudden sensorineural hearing loss is still considered "idiopathic" in 71%-85% of cases, and treatments are empiric, not based on etiology. MR imaging implemented with a 3D FLAIR sequence has provided new insights into the etiology of sudden sensorineural hearing loss. Herein, we review the current management trends for patients with sudden sensorineural hearing loss, from the initial clinical diagnosis to therapeutic strategies and diagnostic work-up. We focused primarily on MR imaging assessment and discuss the relevance that MR imaging findings might have for patient management, pointing out different perspectives for future clinical research.

Sialendoscope-assisted transoral removal of hilo-parenchymal sub-mandibular stones: surgical results and subjective scores

It has been suggested that a conservative trans-oral approach to proximal and hilo-parenchymal submandibular stones (HPSMS) is a valid alternative to the more frequently used sialadenectomy. The aim of this study was to evaluate the surgical, ultrasonographic and patients' subjective outcomes of results of the trans-oral removal of HPSMS. Between January 2003 and September 2015, sialendoscope-assisted trans-oral surgery was used to remove symptomatic, large (> 7 mm), fixed and palpable HPSMS from 479 patients under general anaesthesia. All patients were followed clinically and ultrasonographically to investigate symptom relief and recurrence of stones, and were telephonically interviewed to assess saliva-related subjective outcomes with a questionnaire. Stones were successfully removed from 472 patients (98.5%); the seven failures (1.5%) concerned pure parenchymal stones. One year after the procedure, 408 patients (85.1%) were symptom free, 59 (12.3%) had recurrent obstructive symptoms and 12 (2.6%) had recurrent infections. Of the 54 patients who developed a recurrent stone (11.2%), 52 underwent a second procedure: 29 interventional sialendoscopies, two sialendoscope-assisted intra-corporeal pneumatic lithotripsy, eight secondary transoral surgery to remove residual stones, six a cycle of extra-corporeal lithotripsy and seven submandibular sialadenectomy. Most patients (75.2%) reported mild surgery-related pain. The symptoms of 454 patients (94.8%) improved after adjunctive treatment and, at the end of follow-up, the affected gland was preserved in 98.5% of patients. A sialendoscope-assisted trans-oral removal of large HPSMS is a safe, effective, conservative surgical procedure, and functional preservation of the main duct and parenchyma of the obstructed gland allows sialendoscopic access through the natural ostium in case of recurrence. Combining a trans-oral approach with other minimally invasive, conservative procedures ensures symptomatic relief and salivary duct system clearance in the majority of patients.

Salivary lithotripsy in the era of sialendoscopy

The traditional management of obstructive salivary disorders has been replaced by minimally-invasive gland-preserving techniques including shock-wave lithotripsy, sialendoscopy, interventional radiology and endoscopically video-assisted trans-oral and cervical stone retrieval, of which sialendoscopy is considered to be the method of first choice. Primary endoscopically controlled stone extraction without prior fragmentation is only possible in 15-20% of cases; in more than 80%, fragmentation is necessary because of the size, impactation and location of the stone, or an alternative treatment such as transoral duct surgery or combined approaches are required. Moreover, about 10-20% of all stones cannot be adequately accessed by means of a sialendoscope or any alternative surgical method and, in such cases, extra-corporeal shock wave lithotripsy (ESWL) is the treatment of choice. However, in endoscopically accessible stones, ESWL is being gradually replaced by endoscopically assisted intra-corporeal techniques, including endoscopically guided laser and pneumatic intracorporeal lithotripsy. We describe the currently most widely used techniques for salivary lithotripsy, including ESWL, and endoscopically guided laser, electrohydraulic, electrokinetic and pneumatic intra-corporeal lithotripsy, and discuss their indications given the widespread use of advanced rehabilitative sialendoscopy and combined therapeutic approaches.

Nasal nitric oxide in children with recurrent acute otitis media

Recently, reduced Nasal nitric oxide (nNO) nNO levels have been reported in children with adenoidal hypertrophy predisposing to chronic nasosinusal inflammation. Given the strict anatomic and physiopathologic link between the nasopharyngeal and middle ear compartments, and considering the high prevalence of otitis prone children among those affected with chronic adenoiditis, we designed a study aimed to test any possible difference in nNO levels between non-allergic children with and without recurrent acute otitis media (RAOM) associated with chronic adenoiditis. The study involved 54 children with RAOM (44.4% males; mean age= 7.5±3.5 years) and 51 children without RAOM (47.4% males; mean age= 7.0±3.8 years). nNO levels were significantly reduced in children with RAOM compared to children without RAOM (676.9±250.7 ppb vs 831.8±320.4 ppb, respectively; p= 0.02). Our results could be related to reduced NO production by the ciliated paranasal, nasopharyngeal and middle ear epithelium and the impaired sinusal ostial and Eustachian tube patency due to chronic inflammation, and seem to confirm the involvement of NO pathway in recurrent upper airway infections related to impaired ciliated respiratory mucosa.

Serum 25-hydroxyvitamin D levels in children with recurrent tonsillitis living in Milan

Involvement of 25-hydroxyvitamin D in the etiopathogenesis of tonsillar disease in children is still debated; this study assesses possible differences in serum 25-hydroxyvitamin D levels between 309 Caucasian children (58.1% males; mean age 55.7 ± 31.0 months) living in Milan with a history of recurrent tonsillitis (RT) and healthy controls. Mean serum 25(OH)D levels were significantly reduced in the children with a history of RT (22.0 ± 8.7 ng/mL vs 24.6 ± 7.8 ng/mL; p=0.03), and the proportion of children with insufficient or deficient serum 25(OH)D levels was higher in the RT group (81.5% and 6.5% respectively) than in the control group (75.1% and 3.5%) (not significant). The multivariable model created to test the independent association between serum 25(OH)D levels and a history of RT after adjusting for age and season showed that the association was not significant. Our study failed to find any significant reduction in serum 25(OH)D levels after adjustment for age and season in a case series of children with RT in comparison with healthy controls, which suggests that vitamin D does not play a relevant role in the etiology of pediatric tonsillar infections.

Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children

Allergic rhinitis (AR) is a very common childhood disease that is associated with a significant reduction in the patients' quality of life. Its treatment combines educating the patients and their parents, immunotherapy and drug administration. However, even the best approach does not relieve the symptoms of a number of patients. Alternative therapies are particularly needed for children because the fear of adverse events frequently reduces parental compliance to the prescribed drugs, and immunotherapy is less easy to administer than in adults. In this prospective investigator-blinded study we evaluated whether children, with a documented history of seasonal grass pollen-related AR, benefit from nasal irrigation by assessing the effects on nasal signs and symptoms, on middle ear effusion and on adenoidal hypertrophy. We randomized children aged 5 to 9 years (median age 82 months) to normal saline or hypertonic saline (a 2.7% sodium chloride solution), administered twice-daily using a disposable 20 ml syringe, or no treatment. Nasal symptoms (rhinorrhea, itching, sneezing, nasal obstruction), swelling of turbinates, adenoid hypertrophy or middle ear effusion were assessed at baseline and after 4 weeks of treatment. Two hundred and twenty children (normal saline: 80; hypertonic saline: 80; no treatment: 60) completed the study. After four weeks, all the considered items were significantly reduced in the group receiving hypertonic saline (P < 0.0001), whereas in the group receiving normal saline only rhinorrhea (P = 0.0002) and sneezing (P = 0.002) were significantly reduced. There was no significant change in any of the items in the control group. The duration of oral antihistamines was significantly lower in the children receiving hypertonic saline than in those treated with normal saline or in controls. No adverse events were reported and parental satisfaction and compliance with the procedure were globally very good, regardless of the solution used. Using our procedure, hypertonic saline is effective, inexpensive, safe, well tolerated and easily accepted by children with seasonal grass pollen-related AR and their parents. Our data suggest that nasal irrigation with hypertonic saline might be included in the wide spectrum of therapies recommended for grass-pollen AR.

Submental dermoid cyst: a rare clinical entity in early pediatric age

Herein we describe a rare case of exclusive submental dermoid cyst in the first decade of life. The preoperative ultrasonography (US) and magnetic resonance imaging (MRI) diagnosis was confirmed by the results of a histopathological examination. US followed by MRI is the gold standard for the non-invasive diagnostic differentiation of dermoid cysts from other submental swellings and submental excision remains the best surgical option.

Nasal nitric oxide in children with adenoidal hypertrophy: a preliminary study

OBJECTIVE

Nasal nitric oxide, a mediator involved in upper airway inflammation, is impaired in children with allergic rhinitis and rhinosinusitis. Normal values are 200-450 parts per billion, but no data are available concerning its levels in children with adenoidal obstruction, predisposing to chronic nasosinusal inflammation. This study aimed to: (1) measure nasal nitric oxide levels in non-allergic children with adenoidal hypertrophy and (2) assess its possible relationship with the degree of adenoidal hypertrophy and other variable (gender, age, body max index, passive smoking exposure, recurrent acute otitis media, recurrent respiratory infections, and hypertrophy of nasal turbinates).

METHODS

Eighty-one children with suspected adenoidal hypertrophy underwent nasal fibroendoscopy to assess the degree of adenoidal hypertrophy, and nasal nitric oxide on-line measurements by means of a dedicated chemiluminescence analyser.

RESULTS

Nasal nitric oxide was successfully measured in 35 patients, most of whom had levels >450 parts per billion; the values were significantly higher (p=0.031) in children with non-obstructive adenoids. There was no significant correlation with any other variable.

CONCLUSIONS

Preliminary data show above-normal nasal nitric oxide levels in children with adenoidal hypertrophy, especially those with non-obstructive adenoids. This suggests nitric oxide involvement in recurrent nasopharyngeal inflammation due to adenoidal hypertrophy.

Insights into infectious otitis media

Otitis media is a multifactorial disease. It represents a major public health burden, as it is the most common diagnosis in children and is characterized by both immediate and long-term morbidity. For years the knowledge about risk factors and microbiology of otitis media has been relatively stable. In recent years new data have been gathered regarding different microbiological aspects of otitis media. This new knowledge may contribute toward the development and implementation of therapeutic and preventive strategies.

Role of atypical bacteria in children undergoing tonsillectomy because of severely recurrent acute tonsillopharyngitis

The aim of this study was to verify the frequency of atypical bacterial infections in children undergoing tonsillectomy because of severely recurrent acute tonsillopharyngitis (AT) and the possible benefit of surgery in cases in which Mycoplasma pneumoniae and Chlamydophila pneumoniae seem to play a role in causing the recurrences. A total of 118 patients (76 males; mean age +/- standard deviation, 6.67 +/- 3.31 years) were enrolled: 59 underwent tonsillectomy because of severely recurrent AT and 59 underwent adenotonsillectomy because of obstructive sleep apnea syndrome (OSAS). The results show, for the first time, that the great majority of children with a history of severely recurrent AT (and, therefore, considered to be eligible for elective tonsillectomy) are infected by atypical bacteria, mainly M. pneumoniae, and that tonsillectomy seems to be effective in reducing the recurrence of both AT and acute respiratory disease during 12 months follow-up postsurgery.

Modern management of obstructive salivary diseases

Over the last fifteen years, increasing public demand for minimally-invasive surgery and recent technological advances have led to the development of a number of conservative options for the therapeutic management of obstructive salivary disorders such as calculi and duct stenosis. These include extracorporeal shock-wave lithotripsy, sialoendoscopy, laser intra-corporeal lithotripsy, interventional radiology, the video-assisted conservative surgical removal of parotid and sub-mandibular calculi and botulinum toxin therapy. Each of these techniques may be used as a single therapeutic modality or in combination with one or more of the above-mentioned options, usually in day case or one-day case under local or general anaesthesia. The multi-modal approach is completely successful in about 80% of patients and reduces the need for gland removal in 3%, thus justifying the combination of, albeit, time-consuming and relatively expensive techniques as part of the modern and functional management of salivary calculi. With regard to the management of salivary duct anomalies, such as strictures and kinkings, interventional radiology with fluoroscopically controlled balloon ductoplasty seems to be the most suitable technique despite the use of radiation. Operative sialoendoscopy alone is the best therapeutic option for all mobile intra-luminal causes of obstruction, such as microliths, mucous plugs or foreign bodies, or for the local treatment of inflammatory conditions such as recurrent chronic parotitis or autoimmune salivary disorders. Finally, in the case of failure of one of the above techniques and regardless of the cause of obstruction, botulinum toxin injection into the parenchyma of the salivary glands using colour Doppler ultrasonographic monitoring should be considered before deciding on surgical gland removal.

Treatment of iatrogenic submandibular sialocele with botulinum toxin. Case report

We report the case of a 40-year-old woman with a submandibular sialocele (diagnosed by ultrasonography and magnetic resonance sialography) after sialoadenectomy for sialolithiasis. Type A botulinum toxin was injected percutaneously under colour Doppler ultrasonographic guidance into the sialocele and the residual salivary gland. Five months later the submandibular swelling had gone, and we gave a second injection of botulinum toxin to block any residual secretory activity. There were no side effects. This is, as far as we know, the first published report of the use of botulinum toxin to treat an iatrogenic submandibular sialocele.

Preliminary considerations on the application of the voice handicap index to paediatric dysphonia

Dysphonia is a common paediatric condition. Adult voices are usually evaluated using a set of minimal basic measurements including: endoscopic examination, aerodynamics, perception, acoustics, and self-assessment by the patient. The Voice Handicap Index is the most widely used self-assessment tool, but its use in the paediatric setting has never been reported. Aim of this study was to report Voice Handicap Index ratings in a group of dysphonic children, multi-modally assessed before and after voice therapy. The study involved 28 children (16 female, 12 male, mean age 10.9 years (range 6-12)) presenting chronic hoarseness due to vocal fold nodules (18 cases), unilateral localised oedema (6 cases) or recurrent laryngeal paralysis (4 cases). All received voice therapy for 5-6 months, and underwent voice assessments based on video-endoscopy ratings (size of nodule/ oedema or glottic closure in the case of recurrent laryngeal paralysis), maximum phonation time, GIRBAS scale, spectrograms and a perturbation analysis. All patients also completed the Voice Handicap Index. Aerodynamic, acoustic, perceptual and self-assessment data, before and after voice therapy, were compared using Wilcoxon's test and Student's t test. Correlations between the Voice Handicap Index domains were measured by means of Pearson's correlation coefficient. Post-treatment measurements showed that the nodules/oedema had decreased in size in 18 children following therapy, and two subjects with recurrent laryngeal paralysis showed improved glottic closure. Mean maximum phonation time increased slightly, but the difference was not significant. There was a general reduction in perceptual severity, but this was only significant for parameters G, B and A. Spectrographic analysis showed no significant improvement and, although the mean perturbation analysis values improved, only the difference in jitter values was significant (p = 0.016). Voice Handicap Index was applicable in all cases, and showed a clear and significant improvement (p = 0.0006). The correlations between the three Voice Handicap Index factors were close; no correlation was found between the functional domain and the physical and emotional domains. The Voice Handicap Index is a useful tool in children with dysphonia, but an adapted version validated for paediatric patients is essential.

Intensity and fundamental frequency control in tracheoesophageal voice

Tracheo-oesophageal voice prostheses are currently widely used following total laryngectomy. Data on maximum phonation time and spectrum have been studied by various Authors and are well known. On the contrary, intensity and fundamental frequency control have received little attention. Intensity and fundamental frequency play an important role in the prosodic aspects of speech. Fundamental frequency variations have been studied in tone language speakers, but the ability to voluntarily change intensity and fundamental frequency remain to be fully investigated. Aim of the present study was to analyse the ability of tracheo-oesophageal voice users to change intensity and fundamental frequency. A total of 12 male subjects who underwent total laryngectomy, in whom a tracheo-oesophageal prosthesis had been inserted, were considered. Maximum phonation time was calculated. Each subject was asked to utter an /a/ as loud as possible and an /a/ as soft as possible. Each subject was then asked to utter an /a/ at comfortable pitch and then at an interval of a fifth. Intensity as well as fundamental frequency variations were compared using Wilcoxon signed rank test. Correlation between maximum phonation time and variation in intensity and in fundamental frequency as well as between the two latter variables was calculated using Spearman's rank correlation coefficient. Mean maximum phonation time was 8 (+/- 3.8) sec. Mean energy was 50 (+/- 4.8) dB SPL for soft phonation and 68 (+/- 4.7) dB SPL for loud phonation. The difference observed was statistically significant (p < 0.02). Mean fundamental frequency values were 106 (+/- 14) Hz and 135 (+/- 34) Hz at the interval of a fifth. The difference observed was statistically significant (p < 0.02). Tracheo-oesophageal voice users were able to change intensity and fundamental frequency, but their control was rather poor. Variations in intensity, as well as fundamental frequency, did not show any correlation with maximum phonation time, and were not correlated with each other. In conclusion, the tracheo-oesophageal voice allows small fundamental frequency variations, but their control appears difficult. On the contrary, intensity variations appear larger and control somewhat easier.

Sudden hearing loss and MTHFR 677C>T/1298A>C gene polymorphisms

PURPOSE

Sudden hearing loss (SHL) can be caused by vascular disorders favoring impaired cochlear perfusion. A number of inherited prothrombotic risk factors have been considered in the pathogenesis of vascular impairment and the possible role of genetic alterations has recently been suggested. We aimed to investigate the relationship between SHL and MTHFR 677 and 1298 gene polymorphisms.

METHODS

DNA genotyping was performed on peripheral blood leukocytes in 45 SHL patients and 135 controls.

RESULTS

Wild-type MTHFR (677CC/1298AA) was significantly more frequent in the controls (P=0.01), and gene polymorphisms (677CT, 677TT, 1298AC, 1298CC, compound 677CT/1298AC) were significantly more frequent in the patients (P=0.005; Ptrend=0.001).

CONCLUSION

These data suggest that MTHFR gene polymorphisms may be considered as risk factors for SHL and participate on vascular impairment related to this disorder. Further studies, based on large series of patients, are needed to definitely assess the role of this prothrombotic factor in the etiopathogenesis of SHL.

Extracorporeal shockwave lithotripsy for salivary calculi in pediatric patients

Salivary gland lithiasis is uncommon in pediatric patients. Color Doppler ultrasonography (US) enables an accurate diagnosis of lithiasis to be made without exposure to the radiation of traditional imaging techniques. The development of minimally invasive techniques in the ENT field has made salivary lithotripsy a feasible alternative to traditional invasive surgery. The safety and efficacy of shock wave lithotripsy for salivary calculi were evaluated in pediatric patients. Seven children (5 males; age 4-15 years) with single calculi (mean diameter 4.4 mm) of the submandibular (n = 4) and parotid glands (n = 3) underwent extracorporeal electromagnetic shock wave lithotripsy (EESWL). In four cases the stone was intraductal (two submandibular and two parotideal) and in the remaining three cases it was intraparenchymal (two submandibular and one parotideal). In one case sedative anesthesia was performed. The mean number of therapeutic sessions was five. Patients were followed up clinically and with US for 6-72 months (mean 32 months). Complete disintegration of the calculi was achieved in five cases while in two cases a residual fragment < 2 mm in diameter was observed. None of the patients had recurrence of calculi in the treated gland. Mild self-limited adverse effects (pain, swelling of the gland, self-limiting bleeding from the duct, cutaneous petechiae) were observed in four cases. Our data suggest that EESWL is effective, safe and well tolerated; the minimal invasiveness of the technique suggests that EESWL should be used as the primary approach to salivary calculi in pediatric patients. The continuous US monitoring enables the efficacy of EESWL to be evaluated during both treatment and follow-up, with only slight discomfort for the pediatric patient.

Myringoplasty in children: anatomical and functional results

To assess the results of myringoplasty in children and determine the factors influencing post-operative results a retrospective study of the anatomical and functional results of 41 myringoplasties in children was performed, considering only the cases of uncomplicated perforation that did not require ossiculoplasty or mastoidectomy. The overall success rate was 80.5 per cent after a mean follow-up of 39 months. The mean post-operative air conduction threshold significantly improved in the successful cases with a mean audiological improvement of 11 dB (p<0.05). No post-operative sensorineural hearing loss was observed. There was a significant statistical association between the presence of a dry ear at the time of surgery and good surgical results (p<0.01). Surgical outcome was not affected by the patient's age, the site and size of the perforation, previous adenoidectomy, surgical technique (overlay vs underlay), or the status of the contralateral ear. Our findings suggest that myringoplasty is a valid procedure in the paediatric population that gives good anatomical and functional results. The status of the middle ear (i.e. the presence of a dry ear), significantly improves surgical outcome; and so careful inflammatory changes in the middle-ear mucosa should be evaluated and medical treatment considered before surgery.

Clinical experience with the treatment of T1b glottic cancer by means of horizontal glottectomy

This study describes the oncological and functional results of horizontal glottectomy performed in a series of 37 similar patients with T1b glottic cancers. The 5-year overall and disease-free survival rates were, respectively, 85.4% and 91.0%. Decannulation was always possible within a mean period of 16.2 days, and no patient developed laryngeal stenosis. A bypass naso-gastric tube was removed a mean 4.9 days after surgery, and adequate swallowing was soon obtained. The mean duration of post-operative hospitalization was 16 days and no major post-operative complications were observed. Satisfactory vocal function was obtained in all cases. On the basis of these results, horizontal glottectomy was found to be a reliable and safe procedure for the management of T1b glottic cancer.

Cyclin D1 expression is predictive of occult metastases in head and neck cancer patients with clinically negative cervical lymph nodes

BACKGROUND

The aim of this study was to investigate the value of p53 and cyclin D1 gene expression in predicting the risk of occult lymph node metastases in patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

The expression of cyclin D1 and p53 was evaluated by means of immunohistochemical analysis in 32 HNSCC patients with clinically and radiologically negative lymph nodes in whom metastatic involvement was subsequently demonstrated at histologic examination (pN+). A group of 64 head and neck cancer patients with histologically negative laterocervical lymph nodes (pN0) was used as a control.

RESULTS

Cyclin D1 and p53 expression were observed respectively in 42 (43.7%) and 48 cases (50%). Cyclin D1 expression significantly correlated with tumor extension and advanced clinical stage (p =.002 and p =.001, respectively). At univariate regression analysis, cyclin D1 expression significantly correlated with the presence of occult lymph node metastases (p =. 0007), and it remained an independent predictor at multivariate regression analysis (p =.0059).

CONCLUSIONS

Our study indicates that the expression of cyclin D1 correlates with the presence of occult cervical metastases in head and neck carcinoma patients, thus suggesting that its immunohistochemical evaluation in biopsy samples may be used as an additional tool for identifying patients to be treated with elective neck dissection.

Immunohistochemical and molecular analysis of bax, bcl-2 and p53 genes in laryngeal squamous cell carcinomas

BACKGROUND

We investigated the role of apoptosis and its potential alterations in laryngeal squamous cell carcinomas (LSCCs) by evaluating bax, bcl-2 and p53 protein expression in 50 cases and by characterising the molecular status of the bax and p53 genes.

MATERIAL AND METHODS

p53 and bax gene mutations were investigated by means of PCR/SSCP and direct DNA sequencing, and bax, bcl-2 and p53 protein expression by means of immunohistochemistry.

RESULTS

We identified p53 gene mutations in 17/50 cases (34%); p53 expression in 26 of the 50 cases (52%); bcl-2 expression in 5/50 cases (10%); bax expression in 32/47 cases (68%). 18/33 cases with a wild type p53 gene overexpressed p53 protein: 12 cases (approximately 66%) were bax+/bcl-2-. Of the remaining cases without p53 protein expression, seven cases (approximately 47%) were bax+/bcl-2-.

CONCLUSIONS

Our observations suggest that the overexpression of p53 may contribute to the repression of bcl-2 and the induction of bax expression in LSCCs. However, the fact that a number of cases not expressing p53 did not present any clear up-regulation of bax or down-regulation of bcl-2 suggests that bcl-2 and bax may be regulated by various mechanisms other than p53.

Clinical relevance of cyclin D1 protein overexpression in laryngeal squamous cell carcinoma

PURPOSE

To investigate the prognostic relevance of cyclin D1 gene overexpression in laryngeal squamous cell carcinomas (LSCCs).

PATIENTS AND METHODS

The overexpression of cyclin D1 was analyzed in 149 LSCC patients with a median follow-up duration of 60 months using the DCS6 monoclonal antibody; only cases that overexpressed cyclin D1 in more than 5% of neoplastic cells were considered positive.

RESULTS

Forty-eight cases (32.2%) were immunoreactive to the DCS6 antibody. Cyclin D1 overexpression was significantly associated with tobacco smoking and alcohol consumption, tumor extension, advanced clinical stage, and the presence of lymph node metastases. Univariate analysis showed that a shorter disease-free and overall survival were significantly associated with supraglottic site, tumor extension, advanced clinical stage, and cyclin D1 overexpression. At multivariate analysis, tumor extension and cyclin D1 overexpression were significantly associated with tumor recurrence, whereas tumor extension, supraglottic site and, at a borderline level of statistical significance, cyclin D1 overexpression, were associated with reduced overall survival.

CONCLUSION

The overexpression of cyclin D1 in LSCC is associated with unfavorable clinicopathologic features and represents an independent significant predictor of laryngeal carcinoma prognosis, particularly for disease-free survival. This indicates that cyclin D1 evaluation may be a further useful element for selecting subgroups of patients who should be treated with more aggressive therapies.

The predictive value of p53, MDM-2, cyclin D1 and Ki67 in the progression from low-grade dysplasia towards carcinoma of the larynx

To evaluate the predictive role of the oncogenes p53, MDM-2 and cyclin D1, and the proliferative marker Ki67, in the progression from low-grade dysplasia to carcinoma of the larynx. We studied immunohistochemically a series of 32 low-grade pre-neoplastic laryngeal lesions, 10 of which progressed to invasive carcinoma. Immunoreactivity in more than 10 per cent of the dysplastic cells was detected in five cases immunostained with anti-p53 (approximately 15 per cent), in two with anti-MDM-2 (approximately six per cent), and 11 with anti-Ki67 antibodies (approximately 34 per cent), whereas none of the cases showed cyclin D1 overexpression. No significant association was found between p53 and MDM-2 immunoreactivity and the evolution to carcinoma; on the contrary, Ki67 expression was detectable in all but one of the 10 cases developing an infiltrative tumour (90 per cent), and in two of the 22 cases that did not progress (approximately nine per cent) (p = 0.01). These findings indicate that immunohistochemical assessment of the proliferative index in bioptic samples of dysplastic laryngeal mucosa may be useful in selecting patients who should undergo a more specific follow-up evaluation.

p53 and cyclinX D1 protein expression in carcinomas of the parotid gland

BACKGROUND

p53 and cyclin D1 genes play a central role in the regulation of the G1 phase of the cell-cycle, and are frequently involved in head and neck tumorigenesis.

MATERIALS AND METHODS

By means of immunohistochemistry, we retrospectively investigated the overexpression of cyclin D1 and p53 genes in a series of 28 parotid gland carcinomas. The immunohistochemical analysis was performed using the ABC method and the antibodies DCS6 (for cyclin D1) and CM1 (for p53).

RESULTS

p53 was overexpressed in 12 (42.9%) and cyclin D1 in 6 cases (21.4%). No significant association was found between p53 or cyclin D1 expression and the evaluated clinicopathological parameters of tumor extension, clinical stage, and lymph node or distant metastases. Nevertheless, it is worth noting that all of the patients with a high expression of p53 died of their disease.

CONCLUSIONS

The present data confirm the role of p53 abnormalities in the pathogenesis of salivary gland carcinoma and report, for the first time, the involvement of cyclin D1 gene in these tumors.

Salivary gland stones: US evaluation in shock wave lithotripsy

PURPOSE

To assess the usefulness of ultrasonography (US) in the selection and monitoring of patients with sialolithiasis to be treated with extracorporeal electromagnetic shock wave lithotripsy.

MATERIALS AND METHODS

US was performed in 80 symptomatic outpatients who were to undergo shock wave lithotripsy because they were not candidates for endoral extraction of calculi. The location and diameter of stones and the condition of the affected gland and duct were determined.

RESULTS

Swollen and sclerotic glands and dilated ducts were the most frequently observed characteristics. After lithotripsy, stone clearance or a residual fragment of less than 2 mm in diameter was seen at US in 37 of 56 patients with submandibular gland calculi and in all 24 patients with parotid gland calculi. Favorable outcome after lithotripsy was associated with smaller (less than 7 mm) stone diameter (P < .001) and, in the case of submandibular gland stones, with intraductal location (P < .05). A return to a normal parenchymal echotexture was seen in all patients in whom the stone was completely eliminated; a limited reduction in swelling was observed in patients with residual fragments.

CONCLUSION

US is useful in the selection of candidates for extracorporeal electromagnetic shock wave lithotripsy and in monitoring the progress of treatment.

MDM-2 oncoprotein overexpression in laryngeal squamous cell carcinoma: association with wild-type p53 accumulation

The MDM-2 gene encodes for a nuclear phosphoprotein that binds p53 and inhibits its ability to activate transcription by concealing the p53 activation domain. It has been suggested that MDM-2 overexpression might represent an alternative mechanism by which p53-mediated pathways are inactivated in human tumors. MDM-2 overexpression can be detected by immunohistochemical analysis as a result of gene amplification and/or increased mRNA expression. We studied MDM-2 gene amplification and protein overexpression in 46 and 50 cases, respectively, of laryngeal squamous cell carcinomas previously analyzed for p53 gene alterations. Not one of the cases showed MDM-2 gene amplification, whereas MDM-2 nuclear immunoreactivity was found in 17 tumors (34%). In 10 of these, coexpression of p53 protein was detectable in the absence of gene mutations in exons 5 through 9 (P = .03). Likewise, MDM-2 was also overexpressed in 18 (46%) of 39 morphologically normal mucosa samples, 15 (50%) of 30 preneoplastic lesions, and 9 (40%) of 22 cases of severe dysplasia. Finally, we found no significant correlations between MDM-2 expression (neither per se nor in association with wild-type or mutated p53), and the evaluated clinicopathologic parameters of histologic grade, lymph node status, or clinical stage. Our results suggest that MDM-2 gene amplification might not occur in laryngeal carcinomas and that MDM-2 protein overexpression might represent an alternative mechanism by which p53 is inactivated in the early stages of laryngeal cancer tumorigenesis.

Cyclin D1 protein expression is related to clinical progression in laryngeal squamous cell carcinomas

The expression of cyclin D1 gene was investigated in 74 laryngeal squamous cell carcinomas (LSCCs) in order to determine its clinical and prognostic value. Overexpression of cyclin D1 was detected immunohistochemically using DCS6 monoclonal antibody on formalin-fixed, paraffin-embedded tissue sections. Cyclin D1 expression was detected in 22 of the 74 cases investigated (30 per cent), thirteen of which presented nodal metastases (59 per cent); of the patients without any detectable cyclin D1 protein expression, six presented nodal metastases (12 per cent). Cyclin D1 protein expression was found in five per cent of the specimens of normal mucosa, eight per cent of those with low-grade dysplasia and 20 per cent of those with high-grade dysplasia. A statistically significant association was found between cyclin D1 expression and the supraglottic site (p < 0.05), tumour extension (p < 0.001), the presence of lymph node metastases (p < 0.001), and advanced clinical stage (p < 0.001). Cyclin D1 expression analysis is an important tool in the selection of LSCC patients with an aggressive clinical course.

Molecular and immunohistochemical analysis of the bcl-1/cyclin D1 gene in laryngeal squamous cell carcinomas: correlation of protein expression with lymph node metastases and advanced clinical stage

BACKGROUND

The molecular pathogenesis of laryngeal squamous cell carcinomas (LSCCs) is still only partially understood, although genetic alterations affecting various protooncogenes or tumor suppressor genes have often been detected.

METHODS

To improve their understanding of the role of cyclin D1 in the pathogenesis of LSCCs, the authors investigated the expression of cyclin D1 protein and the amplification status of the bcl-1/cyclin D1 locus in a panel of 58 pathologic samples.

RESULTS

Expression of cyclin D1 protein was detected in 23 of the 58 patients (approximately 39%), 14 of whom had lymph node metastases (approximately 61%); of the remaining 35 patients without any detectable cyclin D1 expression, 7 had lymph node metastases (20%). Expression of cyclin D1 was detectable in 5% of the specimens of normal mucosa, 13% of those with mild-to-moderate dysplasia, and 25% of those with severe dysplasia. Amplification of the bcl-1/cyclin D1 locus was detected in 12 of the 49 LSCCs investigated (approximately 24%), 7 of which had lymph node metastases (approximately 58%); of the remaining 37 LSCCs with an apparently normal copy number of the cyclin D1 locus, 12 had lymph node metastases (approximately 32%). The authors found almost complete concordance between locus amplification and protein expression. Statistical analysis showed a correlation between cyclin D1 expression and both the presence of lymph node metastases (P < 0.01) and advanced clinical stage (P < 0.02).

CONCLUSIONS

The authors' observations suggest that the deregulation of cyclin D1 expression may be involved in the pathogenesis of more aggressive LSCCs.

[Parotid gland sialolithiasis: a new therapeutic option]

In chronic lithiasis of the salivary glands surgery is the only approach available whenever the stone cannot be removed by dilating or dissecting the salivary duct. The introduction of lithotripsy in the treatment of kidney and gall stones has made it possible to apply this method to salivary gland stones as well. The present study was aimed at evaluating the safety, reliability and effectiveness of lithotripsy in 36 patients with symptomatic parotid gland stones which could not be removed by conservative surgery. Ultrasound revealed the stones which were on the average 4.8 mm. In 147 cases they were located in the intraparenchymal area while the remaining 19 cases were located within the duct. No patient required anesthesia, sedative or analgesic. The average number of sessions per patient was 3.8 and each treatment lasted an average of 30 minutes. After lithotripsy, in all 10 of the patients who had completed the treatment, the stone was either totally eliminated or reduced enough to allow for spontaneous elimination. The side effects found in 9 of the patients were minor pain (2 patients), a transitory duct hemorrhage (6 patients) and skin petechia (4 patients). No damage to the salivary glands or adjacent anatomical structures was revealed upon treatment or later during the 10 month average follow up (range 1-22 months). Extracorporeal lithotripsy is a safe, effective, non-invasive alternative therapeutic option for the treatment of parotid sialolithiasis.

p53 and cyclin D1 protein expression in glottic laryngeal squamous cell carcinomas involving the anterior commissure (pT1bN0M0)

The prognosis of patients carrying glottic squamous cell carcinomas (GSCCs) involving the anterior commissure is often unpredictable. In order to assess the possible prognostic role of new and reliable parameters, p53 and cyclin D1 protein expression was immunohistochemically analysed in pathological samples from 27 patients with GSCG (pTlbNOMO) and a median follow-up of 90 months. p53 protein expression was observed in the majority of patients (15/27), but it did not correlate with their clinical outcome; p53 protein immunoreactivity was frequently observed in normal (9/14), mildy dysplastic (10/14) and highly dysplastic (3/7) mucosa samples, suggesting that its overexpression may be involved in the earliest phases of the multistep tumourigenesis of laryngeal squamous cell carcinomas (LSCCs); neither the non-neoplastic nor the neoplastic samples expressed any cyclin D1. As cyclin D1 protein expression has been associated with a high frequency of nodal metastases, its absence in our series could ba related to the rarity of nodal involvement in early glottic LSCCs.

Extracorporeal electromagnetic shock-wave lithotripsy for salivary gland stones

Sialoadenectomy for sialolithiasis is necessary when the stone cannot be removed through the salivary duct. In addition, extracorporeal. shock-wave lithotripsy has recently become available for this purpose. The safety and efficacy of this method was assessed in 52 outpatients bearing stones with an average diameter of 6.76 mm in the submandibular or parotid gland. Anesthetics, sedatives, and analgesics were not required. Twenty-four of the 36 patients with submandibular gland calculi and all 16 with parotid sialolithiasis had complete stone disintegration or fragmentation of the calculi, with possible spontaneous clearance. Untoward effects were observed in 15 patients, namely localized skin petecchiae, transitory swelling of the gland, and self-limiting bleeding from the duct. No persistent damage of the salivary glands or adjacent structures was noted during a mean follow-up period of 10 months.

p53 protein expression in laryngeal squamous cell carcinomas bearing wild-type and mutated p53 gene

We performed an immunohistochemical analysis to investigate the expression of p53 protein in a panel of 18 laryngeal squamous cell carcinomas, 15 primary tumours and three in relapse, previously analysed by us for the presence of p53 gene mutations. Dysplastic and/or normal surrounding mucosa was evaluated in 15 different tumours. The results of our study are the following: (1) expression of p53 protein was observed in one out of five tumours positive for p53 gene mutations (20%) and in 10 out of 13 (80%) negative cases; (2), p53 protein over-expression was frequently observed in normal and/or dysplastic mucosa surrounding either wild-type (7/11) or mutated p53 tumours (2/4); (3), p53 immunoreactive cells showed a pattern of distribution in normal and mildly/ moderately dysplastic mucosa (basal layers), different from that in severely dysplastic mucosa (whole thickness). These data further support the hypothesis that p53 protein over-expression may be a marker of the earliest phases of multistep tumorigenesis in laryngeal squamous cell carcinoma.

Multiple genetic lesions in laryngeal squamous cell carcinomas

BACKGROUND

To understand the molecular pathogenesis of laryngeal squamous cell carcinomas (LSCCs), this study investigated the involvement of various protooncogene loci (bcl-1, int-2, c-erbB-1, c-myc, ras) and the p53 tumor suppressor gene in 18 patients with LSCC (15 at clinical presentation, 3 in clinical relapse).

METHODS

For all patients, the mutations affecting the p53 and the H-, K-, and N-ras genes were evaluated by polymerase chain reaction (PCR), single-strand conformation polymorphism, and the direct sequencing of PCR-amplified fragments. The bcl-1, int-2, c-erbB-1, and c-myc loci of 15 patients were investigated using Southern blot analysis.

RESULTS

A mutation of the p53 gene was detected in 5/18 patients (approximately 28%), bcl-1 locus amplification in 4/15 (approximately 26%), c-erbB-1 locus amplification in 2/15 (approximately 13%), and c-myc locus amplification in 1/15 (approximately 6%). The simultaneous presence of more than one genetic lesion was observed in four patients; two showed int-2/bcl-1 coamplification, and two int-2/c-erbB-1 coamplification, one of whom also showed a p53 gene mutation. A novel p53 mutation involving the splice acceptor site of exon 6 was detected in one patient. Two of the five patients positive for p53 mutations had clinical relapses of primary tumors. bcl-1 locus amplification only was observed in patients with lymph node metastases (4/6). All but one of the patients with molecular genetic lesions showed a peculiar infiltrating pattern.

CONCLUSIONS

Overall, these results show that alterations of known protooncogenes and the p53 tumor suppressor gene are involved in a large proportion of LSCCs (11/18; approximately 60%) and may suggest that distinct molecular pathways occur in the pathogenesis of these tumors.

Carcinoma of the vocal cord. Results after subperichondral cordectomy

The clinical outcome of 110 patients operated upon by subperichondral cordectomy between 1982 and 1992 for T1s/T1a, NO, MO carcinomas of the vocal cord has been evaluated in this longitudinal epidemiological study. Patients have been followed up until the end of 1993 by examinations done once a month (first year), every three months (years 2 to 4), every six months (years 5 to 8), and then once a year. Life-tables have been computed according to Kaplan and Meier and raw survival has been 90.0%. Considering only the mortality due to any type of neoplastic disease, the survival reached 93.6%. Finally, considering only deaths due to recurrences or metastases of the primary tumor, the survival rate was 95.5%. Mortality after the first recurrence was 27.3%, after a second recurrence 50.0%. A correlation between number of cigarettes smoked and the risk of recurrence of the tumor could be observed (p < 0.01), while gross appearance and histologic grading of the vocal cord carcinoma proved to be uncorrelated with the risk of recurrences.