Hemostatic Effect of Tranexamic Acid in Elective Nasal Surgery

Background

Bleeding is the most frequent complication of nasal surgery. The aim of this prospective study was to evaluate the effectiveness of tranexamic acid (TA), an antifibrinolytic agent, in reducing bleeding during and after nasal surgery.

Methods

The study sample included 400 patients aged 18–60 years who underwent combination functional endoscopic sinus surgery with septoplasty and conchotomy. Two hundred patients were not given a hemostatic agent (control group) and 200 patients were administered 1 g of oral TA three times daily starting 2 hours before surgery, for 5 days. Bleeding was monitored during surgery and for 2 weeks postoperatively.

Results

Patients given oral TA showed significantly less operative and postoperative bleeding compared with controls. No patients required additional packing, compared with five patients in the control group. Adverse reactions to TA were minimal, and they disappeared when the treatment stopped.

Conclusion

TA is a safe and effective drug for the reduction of bleeding in nasal surgery. It may be recommended for routine use.

[ENDOSCOPIC RESECTION OF ZENKER DIVERTICULUM - A SINGLE CENTER EXPERIENCE]

BACKGROUND

Zenker diverticulum (ZD) is a pseudodiverticulum and usually affects males in the 6th-9th decade of life, symptoms include dysphagia, regurgitation, chronic cough, aspiration, halitosis and weight loss. Surgery has been the mainstay treatment of symptomatic ZD and can be divided into external and intraluminal (endoscopic) techniques.

METHODS

Charts of all patients who had endoscopic correction of ZD in a tertiary referral center in the last 5 years were retrieved.

RESULTS

Twenty patients, 90% were male, with ZD were reviewed with mean age of 68 +/- 9.5 years. The pre-operative mean pouch size was 3.43 +/- 0.9cm. Intraoperative pouch length was 2.55 +/- 1.5 cm. No major complications such as emphysema and mediastinitis were reported. The recurrence rate was 20%; 3 patients had revision endoscopic procedure and 1 had open surgery.

CONCLUSIONS

Intraoperative length measure of Zenker diverticulum provides a good estimation of its size, with a more discreet and accurate dissection seeming to decrease the rate of major complications. Recurrence rate seems higher in small diverticulum. However, endoscopic treatment of these small diverticulum is safe with a tremendous impact on the patient's quality of life.

Characteristics and outcome of laryngeal squamous cell carcinoma in young adults

Laryngeal carcinoma rarely occurs in the young adult population. Therefore, the optimal treatment for this age group is unclear, specifically regarding organ preservation treatment. In order to assess the distinct characteristics of laryngeal squamous cell carcinoma (SCC) in young adults and describe the effect of treatment on survival, a retrospective chart review of all patients aged <40 years, who were treated in a tertiary referral center for laryngeal SCC between January 1960 and December 2013, was performed. Patients who were treated prior to and following the Veterans study, representing an arbitrary point which started the organ preservation era, were compared. A total of 29 patients (male:female ratio, 2.6:1) were identified. The mean age at diagnosis was 35±5 years and 17 patients (59%) were smokers. In total, 12 (41%) of patients were stage I, 4 (14%) were stage II, 8 (28%) were stage III and 5 (17%) were stage IV. Glottic tumors were present in 20 (69%) of patients and supraglottic tumors in 6 (21%); the site of tumor origin could not be determined in 3 (10%) of patients. Surgery was performed in 11 (38%) of patients, radiation in 21 (72%) and chemotherapy in 5 (17%). A comparison between patients treated prior to and following the Veterans study demonstrated a 2-year higher laryngectomy-free survival rate of 53% and 78%, respectively (P=0.299). The 2-year disease-free survival rate was 93% for patients who were treated prior to the Veterans study and 71% for patients who were treated after (P=0.001), with no significant change in overall survival (P=0.413). The results suggest that the characteristics and behavior of laryngeal carcinoma in young adults is similar to older adults. Higher rates of 2-year laryngectomy-free survival were noted in patients treated following the organ preservation era with no significant difference in survival compared with patients who were treated before.

Phase II organ-preservation trial: Concurrent cisplatin and radiotherapy for advanced laryngeal cancer after response to docetaxel, cisplatin, and 5-fluorouracil-based induction chemotherapy

BACKGROUND

The optimal treatment for locally advanced laryngeal cancer remains controversial. The purpose of this trial was to determine if the response to induction chemotherapy could select patients for organ preservation protocols, and improve larynx-preservation rates without compromising overall survival (OS).

METHODS

The cohort comprised 12 patients with T3 disease and 14 with T4. Induction chemotherapy consisted of docetaxel, cisplatin, and 5-fluorouracil (TPF). Response to the first cycle was determined by examination and positron emission tomography (PET)-CT. Responders (>50% tumor reduction) underwent chemoradiation, whereas nonresponders underwent laryngectomy.

RESULTS

Eighty-three percent of the patients had a response and 17% had stable or progressive disease. At 2 years, the median OS was 80%, the larynx-preservation rate was 83%, and the disease-specific survival rate was 86%. Response to a single TPF cycle was associated with 2-year OS (92% vs 50%; p = .02). The T classification was not predictive of survival.

CONCLUSION

Response to a single TPF-based cycle may identify patients with advanced laryngeal cancer who are amenable to organ preservation treatment. © 2016 Wiley Periodicals, Inc. Head Neck 39: 227-233, 2017.

Is the Delay in Starting Postoperative Radiotherapy a Key Factor in the Outcome of Advanced (T3 and T4) Laryngeal Cancer?

OBJECTIVE: To identify factors influencing the outcome of postoperative radiotherapy in patients with advanced laryngeal cancer.

DESIGN: The files of 44 patients with advanced laryngeal cancer who were treated by surgery followed by radiotherapy (24 with pT3 and 20 with pT4) were reviewed. Median delay in starting radiotherapy was 50 days (range, 19–150 days). Treatment variables, in addition to certain patient and tumor characteristics, were analyzed in terms of locoregional control and survival.

SETTING: Major referral tertiary center in central Israel.

RESULTS: Locoregional control rates were 86% and 81% at 2 and 5 years, respectively, and corresponding survival rates were 82% for both. Only nodal involvement retained statistical significance for both locoregional control as well as survival on multivariate analysis ( P = 0.0009 and P = 0.0004, respectively).

CONCLUSIONS: This is the first study showing that delay in postoperative radiotherapy in advanced laryngeal cancer is not a significant predictor of locoregional control or survival in advanced laryngeal cancer. Only lymphatic spread was found to have a significant influence on treatment outcome.

Radiation-Induced Well-Differentiated Thyroid Cancer: Disease Characteristics and Survival

BACKGROUND

Radiation exposure is a well-known risk factor for well-differentiated thyroid cancer (WDTC). However, disease characteristics, optimal treatment, time from exposure to disease appearance, and the effect of age at initial exposure on the outcome have yet to be determined.

OBJECTIVES

To identify the characteristics of radiation-induced thyroid carcinoma.

METHODS

We retrieved the charts of all patients previously exposed to radiation who were diagnosed with WDTC between the years 1985 and 2013 in a tertiary referral center.

RESULTS

Forty-four patients were reviewed. Median time from radiation exposure to diagnosis was 23 years. These patients had higher rates of aerodigestive symptoms and distant metastases on presentation than seen in non-radiated patients. Patients who were exposed to radiation before age 15 years tended to develop the disease at a younger age but had a longer latency period (34.7 ± 15.3 vs. 16.3 ± 10 years, P < 0.001) and none had significantly higher rates of vocal cord palsy, hoarseness on presentation, or aggressive variants on histology compared to patients exposed to radiation at an older age. Disease-specific survival (DSS) was the same for both groups and were similar to that seen in the general population (95% 20 year DSS).

CONCLUSIONS

Radiation-induced thyroid cancer has a more aggressive presentation and the age at exposure affects the presentation of disease. Nonetheless, appropriate treatment leads to a favorable prognosis.

Radiation-Induced Thyroid Cancer: Gender-Related Disease Characteristics and Survival

BACKGROUND

Radiation exposure is a well-known risk factor for well-differentiated thyroid cancer (WDTC). However, gender disparity in disease characteristics is not completely understood. The purpose of this study was to determine the behavior of radiation-induced thyroid cancer according to gender.

METHODS

Charts of all patients diagnosed with WDTC after radiation exposure between the years 1985 and 2013 in a tertiary referral center were retrieved.

RESULTS

Forty-three patients were reviewed, 29 females and 14 males. Mean age of exposure for women and men were 17.1 ± 19.5 and 15.5 ± 12.5 years, respectively (P = .78). Age at diagnosis were 47.5 ± 15.5 and 41.5 ± 15 years for women and men, respectively (P = .18). Mean disease-specific survival was 44.1 and 43.7 years for women and men, respectively (P = .50).

CONCLUSIONS

Similar disease characteristics, tumor pathology, disease-free survival, and overall survival in both genders. In sporadic well-differentiated thyroid carcinoma, female gender is associated with better tumor behavior and prognosis. However, our results suggest that women are more affected by radiation than men and therefore have the same prognosis as men.

Assessment of margins in transoral laser and robotic surgery

The growing practice of endoscopic surgery has changed the therapeutic management of selected head and neck cancers. Although a negative surgical margin in resection of neoplasm is the most important surgical principle in oncologic surgery, controversies exist regarding assessment and interpretation of the status of margin resection. The aim of this review was to summarize the literature considering the assessment and feasibility of negative margins in transoral laser microsurgery (TLM) and transoral robotic surgery (TORS). Free margin status is being approached differently in vocal cord cancer (1-2 mm) compared with other sites in the upper aerodigestive tract (2-5 mm). Exposure, orientation of the pathological specimen, and co-operation with the pathologist are crucial principles needed to be followed in transoral surgery. Piecemeal resection to better expose deep tumor involvement and biopsies taken from surgical margins surrounding site of resection can improve margin assessment. High rates of negative surgical margins can be achieved with TLM and TORS. Adjuvant treatment decision should take into consideration also the surgeon's judgment with regard to the completeness of tumor resection.

Post-laryngectomy voice rehabilitation: comparison of primary and secondary tracheoesophageal puncture

BACKGROUND

Voice restoration following total laryngectomy is an important part of patients' rehabilitation and long-term quality of life.

OBJECTIVES

To evaluate the long-term outcome of indwelling voice prostheses inserted during (primary procedure) or after (secondary procedure) total laryngectomy.

METHODS

The study group included 90 patients who underwent total laryngectomy and tracheoesophageal puncture (TEP) with placement of voice prosthesis at a tertiary medical center during the period 1990-2008. Background, clinical and outcome data were collected by medical file review. Findings were compared between patients in whom TEP was performed as a primary or a secondary procedure.

RESULTS

TEP was performed as a primary procedure in 64 patients and a secondary procedure in 26. Corresponding rates of satisfactory voice rehabilitation were 84.4% and 88.5% respectively. There was no association of voice quality with either receipt of adjuvant radiation/chemoradiation or patient age. The average lifetime of the voice prosthesis was 4.2 months for primary TEP and 9.06 months for secondary TEP (P= 0.025).

CONCLUSIONS

Primary TEP provides almost immediate and satisfactory voice rehabilitation. However, it is associated with a significantly shorter average prosthesis lifetime than secondary TEP. Chemoradiotherapy and patient age do not affect voice quality with either procedure.

Insular thyroid carcinoma: a retrospective clinicopathologic study

BACKGROUND

Poorly differentiated carcinoma is a rare epithelial tumor that falls between well-differentiated thyroid carcinoma and anaplastic thyroid carcinoma in terms of morphologic appearance and biologic behavior. An insular variant was characterized in 1983. Further study of this neoplasm is warranted owing to its high aggressiveness, propensity to local recurrence and distant metastases, and high associated mortality. Since insular thyroid carcinoma may have varied presentations, treatment should be individualized.

PURPOSE

To describe the experience of a major tertiary medical center with insular thyroid carcinoma over a 7-year period.

MATERIAL AND METHODS

The study sample consisted of 17 patients with poorly differentiated thyroid cancer, insular variant, who were treated and followed at the Department of Otolaryngology, Head and Neck Surgery of Rabin Medical Center, Israel, in 1992-2009. The medical files were reviewed for background data, clinicopathologic features, treatment, and outcome.

RESULTS

The study group included 10 men and 7 women with a mean age of 63 years (range 16-78). Initial treatment was total thyroidectomy, in a single session (n=9) or two sessions (n=8), followed by radioiodine ablation. In addition, five patients received postoperative external beam radiation and one patient received chemotherapy. Nine patients had extrathyroidal extension, seven had vascular invasion, and four had multifocal disease. Distant metastases were present in four patients. Follow-up ranged from 6 months to 12 years. At present, 11 patients are alive and well. Five died of disease, and one died of another cause.

CONCLUSION

Insular thyroid carcinoma is aggressive and difficult to treat. Surgery remains the mainstay of treatment, though multimodality therapy is usually required.

Chondrosarcoma of the larynx

BACKGROUND

Chondrosarcoma of the larynx is a rare tumor. The most common symptom is hoarseness. Treatment is controversial.

OBJECTIVES

To describe six patients with laryngeal chondrosarcoma from a single center.

METHODS

The medical records of a major tertiary hospital were reviewed for all patients with laryngeal chondrosarcoma diagnosed and treated from 1959 to 2010. Data on background, clinical treatment and outcome were collected.

RESULTS

Six patients, all males with a mean age of 53.3 years, were identified. Partial laryngectomy was performed in three patients, and total laryngectomy, local excision, and partial cricoidectomy in one patient each. Four patients had a permanent tracheostomy after surgery. One patient required postoperative chemotherapy and one radiotherapy. Follow-up time was 12-216 months (mean 102 months). Recurrence developed in two patients 2 and 8 years after initial treatment and was treated by salvage surgery in both patients. One patient died during the follow-up from an unrelated cause. The others are currently alive.

CONCLUSIONS

This study supports earlier reports recommending initial treatment with partial or total laryngectomy for laryngeal chondrosarcoma. Long-term follow-up for recurrence is advised. We recommend preserving the larynx, if possible, even if a permanent tracheostomy is necessary.

The role of elective neck dissection in patients undergoing salvage laryngectomy

BACKGROUND

We investigated the risk of neck metastases in patients undergoing salvage total laryngectomy in association with previous radiotherapy.

METHODS

The medical records of 42 patients (51 neck specimens) with clinical N0 classification who underwent salvage total laryngectomy in 2 cancer centers were reviewed. Fourteen patients had previous radiotherapy to the central neck and 28 to the central and lateral neck.

RESULTS

Staging before salvage total laryngectomy was similar in both groups. The risk of neck metastases in the central and central/lateral radiation groups was 12% and 18%, respectively (p = .69). Subgroup analysis revealed that 4 of 8 patients initially presenting with clinically N+ had neck metastases before surgery, versus 2 of 26 for those with clinically N0 (p = .015; relative risk [RR] = 4.67). The risk or metastases in the contralateral neck was 0 of 9.

CONCLUSION

The risk of neck metastases in patients who undergo either central or central/lateral neck radiotherapy is similar. Elective neck dissection seems appropriate in patients undergoing SLR.

Thyroid gland involvement in advanced laryngeal cancer: association with clinical and pathologic characteristics

BACKGROUND

Indications for thyroidectomy during laryngectomy are controversial. We examined whether clinicopathologic features can predict thyroid gland involvement, and the prognostic effect of thyroid gland involvement in patients undergoing total laryngectomy.

METHODS

The study set out to review preoperative assessment, operation findings, pathologic findings, and follow-up data.

RESULTS

Thyroid gland involvement was found in 11 of 53 patients (21%) undergoing total laryngectomy and thyroidectomy. Preoperative work-up failed to predict thyroid gland involvement. Thyroid gland involvement was associated with salvage procedures (p = .025), paratracheal metastases (p = .003), and poor overall survival (hazard ratio = 2.74, p = .008).

CONCLUSIONS

Thyroid gland involvement in patients undergoing total laryngectomy is frequent and is associated with poor prognosis. Preoperative assessment failed to predict thyroid gland involvement. We believe that thyroidectomy should be considered in cases with paratracheal lymphatic spread irrespective of tumor location within the larynx.

Superior Canal Dehiscence Effect on Hearing Thresholds

Objective. Superior semicircular dehiscence syndrome is associated with vestibular symptoms and an air–bone gap component in the audiogram, apparently caused by the creation of a pathological bony “third window” in the superior semicircular canal. The aim of this study was to evaluate changes in auditory air- and bone-conduction thresholds to low- and high-frequency stimuli in an animal model of a bony fenestration facing the aerated mastoid cavity.

Study Design. Anatomic, audiological.

Setting. Tertiary university-affiliated medical center.

Animals. A small hole was drilled in the bony apical portion of the superior semicircular canal facing the mastoid bulla/cavity, with preservation of the membranous labyrinth, in 5 adult-size fat sand rats.

Main Outcome Measures. Auditory brain stem responses to clicks and 1-kHz tone bursts delivered by air and bone conduction before surgery, after opening the bulla, and after fenestration.

Results. After fenestration, a significant air–bone gap was measured in response to clicks (mean ± standard deviation, 37 ± 5.8 dB) and bursts (mean ± standard deviation, 34 ± 14.5 dB). The gap was attributable solely to the significant deterioration in air-conduction thresholds, in the absence of a significant change in bone conduction thresholds. The pattern of auditory brain response changes closely resembled that reported for middle ear dysfunction, namely, an increase in absolute latency of waves I, III, and V without significant alterations in interpeak latency differences.

Conclusions. Bony fenestration of the superior semicircular canal toward an aerated cavity in a rodent model mimics the auditory loss pattern of patients with superior semicircular dehiscence syndrome. The dehiscent membrane accounts for the auditory changes.

[Fat injection as treatment for vocal cord palsy: our experience in 21 patients]

BACKGROUND

Vocal cord palsy is a known complication after various operations but there are cases in which the paralysis is idiopathic. Patients complain of severe hoarseness and especially coughing, dysphagia and aspirations which can cause recurrent pneumonia.

METHODS

In the last 4 years we have been using autogenic fat which is injected into the paralyzed vocal cord, a procedure which causes swelling of the cord toward the healthy cord in order to improve the voice quality and to prevent foreign body aspiration. In this retrospective study, we describe the treatment with fat injections in 21 patients diagnosed at the voice clinic in "Rabin" Medical Center and treated in the Department of E.N.T and Head and Neck Surgery, Campus "Beilinson".

RESULTS

Following the treatment, all patients reported that there were no aspirations, there was an improvement of voice quality, and most of them were satisfied with the treatment. Six patients needed an additional fat injection after several months.

CONCLUSION

A fat injection to the vocal cord is a simple, quick, and easy procedure, without any skin incision in the neck and with short hospitalization. It is especially suitable for patients with a probability of vocal cord palsy recovery. Most of the patients do not need additional injections.

Histopathological changes of the nasal mucosa induced by smoking

Changes in the histopathology of the respiratory epithelium in response to cigarette smoking have been studied in depth in the lungs, but data on the nasal lining are lacking. The aim of the present retrospective study was to investigate the histological changes that occur in the nasal mucosa of smokers compared with non-smokers. The study group included 47 patients who underwent partial resection of the inferior turbinates. Archival nasal tissue samples were collected and examined by light microscopy: the number of goblet cells was counted, and the degree of inflammation, congestion, and edema was graded as mild, moderate, or severe. Epithelial thickness was measured as well. Findings were compared between smokers (n = 21) and non-smokers (n = 26). On statistical analysis, significant differences were found between the smokers and non-smokers in mean number of goblet cells in the nasal epithelium, 43.43 +/- 16.80 vs. 16.23 +/- 5.65 respectively (p < 0.0001), mean edema grade, 2.43 +/- 0.75 vs. 1.12 +/- 0.33 respectively (p < 0.0001), and mean epithelial thickness, 111.9 +/- 25.8 microm vs. 60.4 +/- 18.4 microm respectively (p < 0.0001). The corresponding mean values of congestion were 2 +/- 0.71 and 1.27 +/- 0.67 (p < 0.001), and of inflammation, 1.81 +/- 0.60 and 1.81 +/- 0.85 (NS). In conclusion, the histopathological findings in the nasal mucosa of smokers resemble reported findings in the bronchial respiratory epithelium. The main differences from non-smokers are greater goblet cell hyperplasia and thicker epithelium.

KTP/532 YAG laser treatment for allergic rhinitis

BACKGROUND

The purpose of this study was to investigate the efficacy of the KTP/532 YAG laser to reduce nasal congestion and discharge in patients with allergic rhinitis.

METHODS

Forty-eight patients with symptoms of allergic rhinitis were treated with the KTP/532 laser. All had positive skin tests for common allergens. Treatments were provided on an ambulatory basis in one to three sessions under local anesthesia with lidocaine nose spray. Outcome was determined by daily symptom reports and regular endoscopy examination and interviews for 12 months.

RESULTS

Treatment was very well tolerated. There were no major side effects. At examination after 1 year, nasal obstruction was improved in 69% and nasal discharge in 40% of cases.

CONCLUSION

The KTP/532 YAG laser is effective for the treatment of nasal obstruction and discharge. Comparison with other techniques showed it to be the most effective in reducing nasal discharge. It can be done as an office procedure and does not damage the nasal mucous membrane. The KTP/532 YAG laser is effective as an additional treatment for patients refractory to medication.

Expression of human DNA Topoisomerase II-alpha in squamous cell carcinoma of the larynx and its correlation with clinicopathologic variables

The aggressiveness of laryngeal squamous cell carcinoma (SCC) is unpredictable. Topoisomerase (Topo) II-alpha is an essential nuclear enzyme; its expression rises at the end of the S-G2/M phase and drops at completion of mitosis. This study sought to determine if Topo II-alpha expression can serve as a prognostic factor in laryngeal SCC. Specimens from 56 consecutive patients were immunohistochemically stained for Topo II-alpha, and the number of positive cells in the areas of highest staining was counted in 3 highpower fields (X400) (Topo II-alpha index). Differences in the Topo II-alpha index by the presence or absence of recurrence, tumor stage and grade, and disease course were analyzed statistically. On multivariate Cox regression analysis, the Topo II-alpha index (>70 or < or =70) (P = .008) and tumor grade (P = .034) independently predicted disease-free survival. These findings suggest that high Topo II-alpha expression may be a useful indicator of tumor aggressiveness and poor outcome in laryngeal SCC.

Laryngeal carcinoma in nonsmoking patients

OBJECTIVES

Smoking is a known risk factor for laryngeal carcinoma. We sought to describe the clinicopathologic characteristics and outcomes of nonsmoking patients with laryngeal carcinoma.

METHODS

Of 1,443 patients treated for laryngeal carcinoma between 1960 and 2006, 55 (3.8%) were nonsmokers: 40 (73%) had never smoked and 15 (27%) had stopped smoking 12 years or more before diagnosis. Patient characteristics and outcomes were reviewed.

RESULTS

The study group consisted of 87% men; the mean age at diagnosis was 67 years. All lesions but one were located in the glottis. The 5-year survival rate for the whole group was 85%. Most tumors were detected early. Of 38 patients (69%) with stage T1 disease, there was no significant difference in prognostic features between those who had never smoked and those who had smoked in the past.

CONCLUSIONS

Fewer than 5% of patients with laryngeal carcinoma were nonsmokers. Like smokers, this subgroup was characterized by a male predominance and an approximate age at diagnosis in the seventh decade. Unlike smokers, nonsmokers show a greater predilection for glottic rather than supraglottic disease. There was no difference in prognosis between smokers and nonsmokers, regardless of whether they had smoked in the past.

Human topoisomerase II-alpha is highly expressed in sinonasal-inverted papilloma, but not in inflammatory polyp

Sinonasal-inverted papilloma is a benign tumour with a high rate of recurrence, but possible malignant transformation. Therefore, inves tigation of predisposition to malignant transformation of sinonasal-inverted papilloma gives clinicians the opportunity for adequate trea ment. Topoisomerase II-α (topoII-α) and Ki67 are markers of cell proliferation in both normal and neoplastic tissues and its level o expression could be used as a predictive parameter. Our goal was to investigate by immunochemistry the expression level of topoII-in inverted papilloma, inflammatory nasal polyp and normal sinonasal epithelium and to compare it with expression level of Ki67. TopoI α nuclear immunostaining showed a differential positivity in the investigated cases. The topoII-α index was 30.6 ± 12.8 in inverte papilloma, 10.7 ± 6.6 in the adjacent epithelium of inverted papilloma, but only 2.3 ± 2.0 in the normal sinonasal epithelium. The di ferences in topoII-α expression between inverted papilloma and normal sinonasal epithelia were statistically significant. In inflammator nasal polyp group, topoII-α index was 2.4 ± 2.1, and the difference in the topoII-α index between inverted papilloma and inflammator polyp group was also statistically significant. Nuclear immunostaining for Ki67 followed a similar variation. The Ki67 index was 50.0 ± 20. in inverted papilloma, 9.0 ± 6.6 in the adjacent epithelium of inverted papilloma and 2.4 ± 0.9 in normal sinonasal epithelium. The di ferences in Ki67 expression between inverted papilloma and either adjacent or normal sinonasal epithelia were statistically significan Significant correlation coefficients were found between topoII-α and epithelial thickness (r = 0.70, P > 0.0001), and between Ki67 inde and epithelial thickness (r = 0.71, P> 0.0001). In the inflammatory nasal polyp group Ki67 index was 5.9 ± 3.4. The difference in th Ki67 index between inverted papilloma and inflammatory nasal polyp groups was statistically significant. Significant correlation coeff cient was found between topoII-α index and Ki67 index in inverted papilloma (r = 0.42, P > 0.05). These results suggest that the inverte papilloma contains a significantly higher cell population with proliferative activity by comparison with normal sinonasal and inflamma tory polyp epithelia, showing a significant correlation between topoII-α and Ki67 expression, and indicating that topoII-α could be a independent prognostic factor for a putative malignant transformation.

Adaptation of median partial sternotomy in head and neck surgery

Upper mediastinum involvement in diseases of the head and neck may require a sternal split. This study describes our adaptation of the upper median or "minimal" sternotomy technique for the treatment of head and neck pathologies. Between April 2002 and October 2005, 17 patients aged 4 to 82 years underwent minimal sternotomy in our institution for a variety of head and neck pathologies. The 17 patients included 11 adults with metastatic thyroid disease (six metastatic papillary thyroid carcinoma, two medullary carcinoma, and one Hiirthle cell carcinoma) and huge retrosternal goiter (n = 2), four adults with parathyroid disease (two primary parathyroid adenoma, one secondary hyperplasia, and one parathyroid carcinoma), and two children with lymphangioma and huge thymic cyst (one each). Average hospitalization was 8 days. Four patients needed a thoracic drain for 2 days, one had recurrent laryngeal nerve palsy, and one had phrenic nerve paresis. There were no postoperative deaths. Minimal sternotomy appears to be an excellent alternative for surgical exploration of the mediastinum and may be used in head and neck surgery for a range of indications.

Adaptation of Median Partial Sternotomy in Head and Neck Surgery

Upper mediastinum involvement in diseases of the head and neck may require a sternal split. This study describes our adaptation of the upper median or “minimal” sternotomy technique for the treatment of head and neck pathologies. Between April 2002 and October 2005, 17 patients aged 4 to 82 years underwent minimal sternotomy in our institution for a variety of head and neck pathologies. The 17 patients included 11 adults with metastatic thyroid disease (six metastatic papillary thyroid carcinoma, two medullary carcinoma, and one Hürthle cell carcinoma) and huge retrosternal goiter (n = 2), four adults with parathyroid disease (two primary parathyroid adenoma, one secondary hyperplasia, and one parathyroid carcinoma), and two children with lymphangioma and huge thymic cyst (one each). Average hospitalization was 8 days. Four patients needed a thoracic drain for 2 days, one had recurrent laryngeal nerve palsy, and one had phrenic nerve paresis. There were no postoperative deaths. Minimal sternotomy appears to be an excellent alternative for surgical exploration of the mediastinum and may be used in head and neck surgery for a range of indications.

Clinical and operative management of persistent hyperparathyroidism after renal transplantation: A single-center experience

BACKGROUND

Persistent (tertiary) hyperparathyroidism (TH) after renal transplantation may cause considerable morbidity and necessitate parathyroidectomy. This study investigated the characteristics of this patient subgroup.

METHODS

The medical data and pathology specimens of 20 kidney transplant recipients who underwent parathyroidectomy for TH in 2001 to 2004 were reviewed.

RESULTS

Treatment consisted of subtotal resection of 3.5 glands in 13 patients, resection of 3 to 3.5 glands under intraoperative parathyroid hormone monitoring (iPTH) in 5 patients, and selective resection in 2 patients with markedly asymmetric gland enlargement. Eighteen patients had hyperplasia-diffuse in 10, nodular in 4, or both in 2; 2 patients had 1 large nodule in every gland. Six patients had postoperative complications. Follow-up of 2 years revealed recurrent hypercalcemia in 1 patient and a high level of PTH (>60 pg/mL) in 12.

CONCLUSION

Subtotal resection for TH may be insufficient. The use of iPTH monitoring is recommended. Renal transplant recipients have distinctive characteristics and require special perioperative attention.

Endoscopic laser surgery for subglottic stenosis in Wegener's granulomatosis

PURPOSE

Wegener's granulomatosis (WG) is a rare multisystem inflammatory disease, which infrequently involves the subglottic area and trachea. Treatment usually involves the use of immunosuppressive agents with corticosteroids. Some patients, however, continue to have symptoms of airway obstruction after clinical remission following the standard therapeutic regimen.

OBJECTIVE

To investigate laser treatment for subglottic stenosis in five patients suffering from WG.

MATERIALS AND METHODS

We endoscopically treated 5 patients with subglottic stenosis due to WG and airway obstruction by Nd:YAG and CO2 lasers. One of the patients had preoperative tracheostomy and after treatment was decannulated and could not breathe without dyspnea. Another patient required stenting of the subglottic area.

RESULTS

All five patients were able to breathe without dyspnea after the treatment. Three patients were treated with an Nd:YAG laser but needed repeated laser treatment every four to six months, whenever they complained of dyspnea. The other two patients were treated with a CO2 laser; one of these patients had preoperative tracheostomy and was treated twice by CO2 laser and decannulated, with no further difficulty in breathing. The follow-up period was 1-5 years.

CONCLUSIONS

Nd:YAG and CO2 lasers are recommended in the treatment of subglottic stenosis (SS) due to WG, particularly when the stenosis is in continuity or close proximity to the vocal cords.

Endoscopic transnasal repair of choanal atresia

OBJECTIVES

To present our experience with a new endoscopic technique for transnasal repair of choanal atresia.

METHODS

Seventeen patients aged 2 months to 13 years with choanal atresia, bilateral in 6 and unilateral in 11, underwent endoscopic repair using a mucoperichondrial flap developed from the nasal septum. The bony stenosis was opened with a surgical curette or drill, and the raw surface was covered by the flap. All patients in these case series with bilateral atresia had been treated with dilatation at birth and had restenosis.

RESULTS

A total of 23 choanae were operated. Follow-up ranged from 10 to 60 months. There was one case of complete restenosis and one of partial restenosis, for a success rate of 91%.

CONCLUSIONS

Endoscopic repair of choanal atresia is a safe and rapid procedure even in very young children, with no complications and a high rate of success.

[Contact endoscopy of the vocal cords]

Contact endoscopy (C.E) of the vocal cord is a new technique for diagnosis of lesions in the vocal cords. This technique is very easy and provides immediate results of the cytological structure of the suspected lesion, assisting in decision-making regarding treatment and follow-up. In the last three years we began using C.E. This study presents our experience with six patients and a review the literature. The C.E technique is an important tool for early diagnosis of lesions of the vocal cord. We believe that in the future, with the technical development of C.E., it will be used routinely not only in the larynx but also in other areas of the body.

Hyperfunctioning intrathyroid parathyroid gland: A potential cause of failure in parathyroidectomy

BACKGROUND

The surgical success rate of parathyroidectomy is 95%. However, in rare patients, ectopic hyperfunctioning parathyroid glands may be located in the thyroid but missed on imaging studies or during surgery. The aim of the present study was to evaluate the perioperative findings in 6 patients with intrathyroid parathyroid glands treated for hyperparathyroidism in our center over a 5-year period and to review the relevant literature.

METHODS

Of the 426 patients who underwent parathyroidectomy for hyperparathyroidism between 1998 and 2003 in our center, 6 (1.4%) were found to have intrathyroid glands. Their files were reviewed for clinical features, surgical approach, intraoperative findings, parathyroid gland location, and morphologic and histopathologic characteristics.

RESULTS

The group included 2 men and 4 women of mean age 66 years. The diagnosis in all patients was based on an increase in serum calcium concentration (10.1-13 mg/100 mL) and parathyroid hormone level (102-320 pg/mL). The clinical symptoms were kidney stones, gastrointestinal complaints, hypertension, and osteopenia. Localization studies included ultrasonography in all patients and sestamibi in 4. When the parathyroid glands were not identified, bilateral neck and mediastinum were explored. Adenoma was diagnosed histologically in 4 patients; 2 had a double adenoma.

CONCLUSION

Intrathyroid parathyroid gland is a rare condition in patients with hyperparathyroidism. In these patients, imaging may miss the pathologic gland. Despite its rarity, the possibility of an intrathyroid parathyroid should be kept in mind, and, when meticulous bilateral exploration of the neck fails to identity the hyperfunctioning gland, the surgeon should consider hemithyroidectomy.

Hemostatic effect of tranexamic acid in elective nasal surgery

BACKGROUND

Bleeding is the most frequent complication of nasal surgery. The aim of this prospective study was to evaluate the effectiveness of tranexamic acid (TA), an antifibrinolytic agent, in reducing bleeding during and after nasal surgery.

METHODS

The study sample included 400 patients aged 18-60 years who underwent combination functional endoscopic sinus surgery with septoplasty and conchotomy. Two hundred patients were not given a hemostatic agent (control group) and 200 patients were administered 1 g of oral TA three times daily starting 2 hours before surgery, for 5 days. Bleeding was monitored during surgery and for 2 weeks postoperatively.

RESULTS

Patients given oral TA showed significantly less operative and postoperative bleeding compared with controls. No patients required additional packing, compared with five patients in the control group. Adverse reactions to TA were minimal, and they disappeared when the treatment stopped.

CONCLUSION

TA is a safe and effective drug for the reduction of bleeding in nasal surgery. It may be recommended for routine use.

Cholesterol granulomas in antrochoanal polyps: a clinicopathologic study

The purpose of this study was to investigate antrochoanal polyps with cholesterol granuloma (CG), which is a granulomatous reaction to cholesterol crystals that has been precipitated in the tissue. It is usually associated with chronic middle ear disease, common in the mastoid air cells, less common in the orbit and rarely found in the paranasal sinuses. The aim of this study was to analyze the etiology and pathological findings of antrochoanal polyps associated with cholesterol granuloma. This is a retrospective study of five cases of antrochoanal polyp with cholesterol granuloma, (four males and one female between 15 and 77 years of age) who presented with nasal obstruction, rhinorhea and snoring. The cases were clinically and histologically reviewed. Four patients were treated endoscopically and one by intranasal polypectomy without endoscope. There was no recurrence during the follow-up between 24 to 36 months (mean 31.2 months). Five uncommon cases with antrochoanal polyp with cholesterol granuloma are presented. The cholesterol granulomas consist of fibrous granulation tissue containing cholesterol crystals with surrounding foreign body giant cells. The pathogenesis of antrochoanal polyp with cholesterol granuloma is unclear, and further investigations are needed.

Lateral minimal parathyroidectomy: safety and cosmetic benefits

BACKGROUND

Surgery has been the cornerstone of treatment for primary hyperparathyroidism for almost three decades. The recent application of state-of-the art imaging technologies to localize hyperfunctioning adenomas preoperatively has enabled surgeons to minimize the surgical procedure, reduce total operation time and improve cosmetic results without compromising the cure rate.

STUDY DESIGN

Twenty-one patients with a diagnosis of primary hyperparathyroidism were selected for treatment with the lateral minimal parathyroidectomy approach following preoperative imaging with ultrasonography, Tc-sestamibi scan, or both. All patients were followed during hospitalization and for three months after for calcium levels and cosmetic results.

RESULTS

The procedure was performed by the same surgical team for all 21 patients; under general anesthesia in 20 patients and under deep sedation in 1 patient at high surgical risk. In all cases, parathyroid adenoma was accurately localized by at least one of the imaging modalities before surgery: ultrasonography in 16 patients (76%), Tc-sestamibi scan in 15 (71%), and both in 10 (48%). Average total operative time for the lateral minimal invasive approach was 46 minutes (range 30-65 minutes). Blood calcium levels returned to normal in all patients, and cosmetic results were graded good to excellent.

CONCLUSIONS

With accurate preoperative localization of unilateral parathyroid adenoma by any imaging modality and careful patient selection, lateral minimal parathyroidectomy performed by a skilled surgeon may serve as a safe, effective procedure with good clinical and aesthetic outcomes.

Expression of p53, Ki-67 and Bcl-2 in parathyroid adenoma and residual normal tissue

The aim of this study was to investigate the expression of Ki-67, bcl-2 and p53 in parathyroid adenomas and their residual rim of normal parathyroid tissue. Specimens from 26 parathyroid adenomas were studied by immunohistochemical analysis for Ki-67, bcl-2 and p53 expression. Positive findings were noted for p53 in 4 (15%) adenomas and none of the residual rims of normal parathyroid tissue (p = 0.055); for Ki-67 in 15 (56%) adenomas and none of the residual rims of normal parathyroid tissue (p = 0.00002); and for bcl-2 in 19 (73%) adenomas and 8 (31%) residual rims of normal parathyroid tissue (p < 0.01). The high rate of Ki-67 expression may indicate susceptibility of parathyroid adenomas to clonal proliferation. The weak immunoreactive expression of p53, combined with a relatively strong expression of bcl-2, may contribute to the characteristic slow progression of these tumors.

Immunohistochemical profile and treatment of uncommon types of thyroid carcinomas

The distinction of uncommon types of thyroid carcinomas is important, because their treatment and prognosis differ. The aim of this study was to describe retrospectively the immunohistochemical profile of uncommon types of thyroid carcinomas and mode of treatment. Of the 1194 patients with thyroid carcinomas treated in Rabin Medical Center from 1954 to 2001, 153 were uncommon types (not papillary or follicular carcinomas). Specimens from archival tissue obtained from thyroidectomies in all these cases were revised and immunohistochemically examined. Anaplastic carcinomas (n=59) were positive for high molecular weight cytokeratin (CK HMW), low molecular molecular weight cytokeratin (CK LMW), cytokeratin (CK) 7, CK 8 and 18, thymoglobulin, EMA and vimentin; medullary carcinomas (n=39) were positive for CK LMW, CK 19, CK 8 and 18, CK 10, CK 7, carcinoembryonic antigen (CEA) and calcitonin; Hurthle cell carcinomas (n=30) for CK LMW, CK 19, CK 8 and 18, thyroglobulin, epithelial membrane antigen (EMA) and CEA; squamous cell carcinomas (SCC) (n=12) for CK HMW and cytokeratin total (CKs); lymphomas (n=7) for leukocyte common antigen (LCA) and B-cells (CD 20), and clear cell carcinomas (n=6) for CK LMW, CEA and thyroglobulin. Use of an immunohistochemical panel has diagnostic value in the differentiation of uncommon types of thyroid carcinoma, which help to plan the best mode of treatment.

Endoscopic laser-assisted posterior ventriculocordectomy without tracheostomy for bilateral vocal cord immobility

BACKGROUND

Laryngeal obstruction due to bilateral vocal cord immobility in adduction may cause dyspnea, hoarseness and dysphagia and can lead to dependence on a tracheostomy. Treatment poses a challenge because of the opposing functions of the larynx and the risk of neck and laryngeal tissue damage.

OBJECTIVES

To describe our experience with endoscopic CO2-laser-assisted posterior ventriculocordectomy without tracheostomy for the treatment of bilateral vocal cord immobility in adduction.

METHOD

The study group consisted of five male and five female patients aged 17-81 years. The procedure was performed with an endoscope and operating microscope connected to a CO2 laser. A C-shaped incision was made, and the posterior third of one vocal cord, the vocal process of the arytenoid, and the posterior third of the false vocal cord were excised. Tracheostomy was not performed.

RESULTS

The technique allowed for a convenient approach to the difficult-to-view areas of the larynx. The procedure was short and bloodless, with minimal damage to laryngeal tissue and no local edema. Hospitalization time was short. Postoperatively, patients had sufficient breathing and mostly fair to good voice quality. None of the patients had severe aspirations and only three patients had mild aspirations.

CONCLUSIONS

We recommend this procedure for patients with bilateral vocal cord immobility prior to tracheostomy. Delaying surgery beyond the time of possible re-innervation may place the patient at risk of decompensation, which requires tracheostomy.

Laser posterior ventriculocordectomy with partial arytenoidectomy for the treatment of bilateral vocal fold immobility

Bilateral vocal fold immobility in adduction usually creates severe dyspnoea. Many surgical procedures have been established to improve the airway insufficiency in affected patients. Over the last six years 22 patients with bilateral vocal fold immobility in our department have undergone CO(2) laser posterior ventriculocordectomy with partial arytenoidectomy (PVCPA). None had dyspnoea or a disturbance in the immediate post-operative period or during follow up, which ranged from five months to six years. Only one patient required a second procedure. Laser PVCPA appears to be an effective and reliable method for the treatment of bilateral vocal fold immobility in selected patients.

Laser surgery for the treatment of glottic carcinomas

PURPOSE

The standard treatment for patients with early glottic carcinoma in Israel has been radiotherapy. In recent years, encouraging results with laryngo-microscopic carbon dioxide laser surgery as a treatment for early glottic carcinoma has changed our treatment strategy. We conducted a retrospective study to investigate the results of carbon dioxide laser excisional technique for early glottic carcinoma (T1, T2).

MATERIALS AND METHODS

Twenty-six had squamous cell carcinoma (SCC), (21 patients with T1 and 5 patients with T2 lesions), 3 had carcinoma in situ, (CIS) and 3 had verrucous carcinoma (VC).

RESULTS

All patients were free of disease after salvage treatment at the most recent follow-up.

CONCLUSIONS

Careful patient selection with endoscopic staging and strict follow-up are essential to secure good results in the treatment of carbon dioxide laser for early laryngeal carcinoma.

[CO2 laser surgery for the treatment of vocal cord carcinomas in early stages (T1 T2)]

BACKGROUND

The standard treatment for patients with early vocal cord carcinoma has been radiotherapy. In recent years, encouraging results with CO2 laser surgery has changed our treatment strategy in selective cases. During the past four years at the Rabin Medical Center we have treated patients with carcinoma of the vocal cord using CO2 laser surgery.

PURPOSE

We conducted a retrospective study to investigate the results of the Head and Neck Surgery department with CO2 laser treatment for squamous cell carcinoma of the vocal cord during early stages (T1, T2) without radiotherapy.

MATERIALS AND METHODS

Twenty one patients with carcinoma of the vocal cords in early stages were treated with CO2 laser. Nineteen patients suffered from stage T1 carcinoma located in one vocal cord, three of these patients suffered from involvement of the anterior commissure and one patient also had involvement with the anterior part of the second vocal cord. Two patients with carcinoma in stage T2, one with involvement of the ventricular band and one with limited movement of the vocal cord. The follow-up period for the patients ranged from one month to four years.

RESULTS

Only one patient in stage T1 developed local recurrence after half a year, no patients died during the follow-up.

CONCLUSION

Careful patient selection with endoscopic staging also during the biopsy, removal of the carcinoma in free border, strict follow-up and stroboscopic examination are essential to secure good results in the treatment of CO2 laser for early stages of vocal cord carcinoma.

[The endoscopic approach to isolated sphenoid sinus disease]

We reviewed the records of 38 patients aged 16 to 76 years with isolated sphenoid sinus disease who were treated by intranasal endoscopic sphenoidotomy at our hospital during the period 1992-1997. Diagnosis was made on the basis of history rigid nasal endoscopy and computed tomography (CT) scan of the sinuses. Headache was the main symptom in 29 (76%) patients. Other complaints were rhinitis, cough, nasal obstruction and nasal bleeding. Sphenoidotomy was performed endoscopically, directly through the area of the natural ostium. Acute or chronic sinusitis was found in 57% of the patients, cysts in 13%, polyps in 10%, mucocele in 8%, and fungal infection, pituitary adenoma, inverted papilloma and adenocarcinoma, in 3% each. Surgical results were excellent. The endoscopic approach proved to be both safe and effective.

CONCLUSION

Sphenoid sinus disease is mostly inflammatory in origin. The endoscopic approach to the sphenoid sinus is currently the most appropriate method of surgery for an isolated sphenoid lesion.

Histological changes in the cervical lymph nodes after radiotherapy

Radiotherapy to the neck is frequently employed in the treatment of malignancies, sometimes alone and sometimes before or after surgery or with or without chemotherapy. We checked the histopathological changes in the neck after radiotherapy, dividing the changes into two groups. One with short-term changes between six months to one year, and the second group with long-term changes after more than six years. We compared these two groups with a control group without radiotherapy. The changes in the long-term group were more pronounced than in the short-term group, with more stromal fibrosis, vascular changes, and specially lymph nodes smaller than one centimeter. Thus, bigger lymph nodes (more then one centimeter) are more radiosensitive and become smaller after six years.

Capsular collagen staining of follicular thyroid neoplasms by picrosirius red: role in differential diagnosis

A key criterion in the diagnosis of thyroid follicular carcinoma is capsular invasion, but invasion cannot always be demonstrated histologically. Since invasion is likely to evoke reactions in the capsular collagen, we examined the effects of invasion on capsular collagen with the picrosirius orange-red (PSR) staining technique for collagen. Under polarized light, the color of PSR-stained collagen varies as a function of the structural and biochemical properties of the collagen fibers. Capsules of widely invasive carcinomas (n = 10), minimally invasive carcinomas (n = 10), and adenomas (n = 28) were stained with the PSR method. Carcinomas were assessed along the thickened capsule for sites of definite invasion, minimal invasion, and no evidence of invasion. In adenomas, sites of thickened capsules (similar to carcinomas) were compared to sites of thin capsules. All foci were evaluated for the color and color intensity of collagen fibers. We found a significantly higher frequency of yellow-green collagen fibers than of orange-red fibers at sites of invasion, whereas orange-red fibers significantly predominated at non-invaded sites. In a minority of cases both colors occurred but the non-dominant color was of lesser intensity in all but 1 case. There were no significant differences in staining between minimally and widely invasive carcinomas. Thick capsules of adenomas consistently stained with an intense orange-red color, although weakly stained yellow-green fibers were also observed in some of these cases. We conclude that PSR staining can provide diagnostically useful information in capsular samples of carcinomas, when both color and color intensity of PSR staining are evaluated at the same site. Specifically, intense yellow-green birefringence of collagen in a thickened capsule is additional evidence for capsular invasion.

Laryngeal carcinoma--epidemiological and clinical features: experience of the Rabin Medical Center in Israel

We sought to compare the epidemiological and clinical features of patients with carcinoma of the larynx treated at a major Israeli tertiary facility with other series in the literature. The charts of 361 consecutive patients from 1974 to 1995 were reviewed. Our population was distinguished from other series by a low rate of alcohol abuse (12%), high incidence of second malignancies in sites other than the upper aerodigestive tract (53%) and high rate of early-stage tumors (82%). Overall 5-year survival and local control rates were 88% and 85%, respectively. Our study suggests that the low alcohol consumption and high proportion of early-stage tumors at diagnosis, characteristic of the Israeli population of patients with laryngeal carcinoma, may explain, in part, the relatively high survival and local control rates.

Neck-dissection surgical specimens treated by lymph node revealing solution

The detection of metastatic lymph nodes in cancer patients is essential for determining the cancer stage, and thus, the therapeutic modalities. However, very small lymph nodes can easily be missed during routine examination. We described a "Lymph Node Revealing Solution" (LNRS) that helps to detect tiny lymph nodes in neck dissection specimens. Twenty-one consecutive specimens of neck-dissection were investigated. The entire surgical specimen, fixed at first in formalin, was searched for lymph nodes by the traditional method. These were excised and sent for processing. The remaining tissue was immersed for 24 hours in LNRS. The lymph nodes stood out as white chalky nodules on the background of the yellow fat. They were then excised, and examined. A total of 227 lymph nodes were detected by the traditional method; 38 (17%) were positive for metastasis. Using the LNRS method, an additional 72 nodes were identified, among them 8 (11%) were positive for metastases and 2 cases were upstaged. LNRS is an inexpensive and easy method of detecting tiny lymph nodes; it enhances significantly the yield of normal and metastatic nodes of neck-dissection specimens and helps to establish a more accurate staging.