Otogenic brain complications: a systematic review and meta-analysis

OBJECTIVE

This study aimed to form astute deductions regarding the presentation, treatment and mortality of otogenic brain complications.

METHODS

A systematic literature search of four medical databases (PubMed, Embase, Web of Science and Scopus) was conducted. Studies associated with otogenic brain complications were considered eligible. Fixed- and random-effects model meta-analysis was developed to assess the proportion estimate for each outcome individually.

RESULTS

Twenty-eight studies, with 1650 patients in total, were included. In 66 per cent of patients there was a known history of chronic otitis media. The most common symptoms were purulent otorrhoea (84 per cent), headache (65 per cent) and otalgia (45 per cent). A brain abscess was observed in 49 per cent of patients, followed by meningitis (34 per cent) and sinus thrombosis (22 per cent). A combination of surgical and conservative therapy was chosen in 84.3 per cent of cases and the mortality rate approached 11.1 per cent.

CONCLUSION

Otogenic brain complications are a possibly life-threatening condition. Prompt imaging examination may set the final diagnosis and lead to an effective treatment.

Endoscopic Versus Microscopic Tympanoplasty: A Systematic Review and Metanalysis

OBJECTIVE

Endoscopic ear surgery is no longer a promising technique, but a well-established one. This study aims to compare endoscopic and microscopic tympanoplasty based on current literature evidence, in terms of their efficacy and safety characteristics.

DATA SOURCES

We conducted a systematic literature search of four medical databases (Pubmed, Cochrane Library, Scopus, ClinicalTrials.gov), focusing on randomized controlled or observational studies comparing microscopic to endoscopic tympanoplasty.

REVIEW METHODS

Data related to the efficacy and safety of each technique were extracted. Outcome data were summarized using pooled mean differences or pooled odds ratio along with their 95% confidence intervals. The risk of bias was estimated, by using the ROBINS-I and RoB-II assessment tools, while the overall quality of evidence was evaluated according to the GRADE working group.

RESULTS

Thirty-three studies, with 2646 patients in total, were included in the meta-analysis. Success rate was evaluated by estimating tympanic graft failure (pooled mean difference:-0.23; 95% CI: -0.61, 0.14, I2  = 33.42%), and air-bone gap improvement (pooled mean difference:-0.05; 95% CI:-0.23, 0.13, I2  = 52.69%), resulting in comparable outcomes for the two techniques. A statistically significant difference favoring the endoscopic technique was detected regarding postoperative wound infection (OR: -1.72; 95% CI: -3.39, -0.04, I2  = 0%), dysgeusia (OR: -1.47; 95% CI: -2.47, -0.47, I2  = 0%), otitis externa development (OR: -1.96; 95% CI: -3.23, -0.69, I2  = 0%), auricular numbness (OR: -2.56; 95% CI: -3.93, -1.19, I2  = 0%), as well as surgical duration (OR: -1.86; 95% CI: -2.70, -1.02, I2  = 43.95%), when compared to the postauricular microscopic approach.

CONCLUSION

Endoscopic tympanoplasty is an innovative alternative to the microscopic technique, resulting in commensurate outcomes regarding success rate. Furthermore, it offers superior results concerning postoperative complications, while it presents a significant reduction in the duration of surgery, mainly when it is compared to the postauricular microscopic approach.

LEVEL OF EVIDENCE

NA Laryngoscope, 2024.

Quality of Life in Patients With Well-Differentiated Thyroid Carcinoma After Total Thyroidectomy in Greece

INTRODUCTION

Well-differentiated thyroid cancer is among the most common types of endocrine cancer. Despite its increasing prevalence, the prognosis of thyroid cancer is rather good, with a five-year survival rate ranging between 80% and 90%, depending on the histological type. Not only the post-treatment complications and the side effects of the lifelong medication but also the possibility of a recurrence may have a negative impact on the patient's quality of life (QoL).

OBJECTIVE

The aim of this study is to investigate the impact of total thyroidectomy on the QoL of patients with well-differentiated thyroid carcinoma.

METHODS

A prospective study was performed in patients who underwent total thyroidectomy due to well-differentiated thyroid carcinoma in the Otolaryngology-Head and Neck Surgery Department at the University Hospital of Larissa, Greece. The QoL was evaluated based on the "Quality of Life (Thyroid Version)" questionnaire.

RESULTS

One hundred patients participated in the study, with a mean age of 51.24±15.33 years. Of these, 63 (63%) were females and 37 (37%) were males. Social concerns, physical well-being, and psychological well-being presented a gradual positive alteration during the first 12 months after the surgery, with psychological well-being reporting the most significant progress of 15.3%. However, spiritual well-being appeared to decline over time. The younger patients progressively improved their physical, psychological, and mental well-being; however, the older patients showed an amelioration of their social skills. Female patients reported higher levels of spiritual well-being, whereas males developed better social skills.

CONCLUSIONS

In the long term, total thyroidectomy can ameliorate patients' physical status, psychological well-being, and social concerns. However, it might have a negative effect on their mental health during the first 12 months postoperatively. In addition, QoL is directly influenced by demographic characteristics such as age and gender.

Middle Ear Adenomatous Neuroendocrine Tumor: A Rare Entity

Middle ear adenomatous neuroendocrine tumors (MEANT) are rare, mainly benign neoplasms and account for less than 2% of the middle and inner ear neoplasms. There are no specific radiological or clinical findings; therefore, the diagnosis is often difficult. Biopsy prior to surgery is often proposed. The definite treatment is the complete surgical resection. We present an uncommon clinical report of a MEANT, which was treated successfully with surgical excision.

Epistaxis Treatment Options: Literature Review

Epistaxis means bleeding from nostrils, nasal cavity or nasopharynx. To summarize the available epistaxis treatment options. Methods: 61 articles published in the last 20 years were included. Duplicate records, irrelevant and inaccessible ones were excluded.  Epistaxis can be treated with first aid measures such as external pressure and ice packing and applying topical agents, e.g. oxymetazoline that stops 65-75% of nosebleeds in A&E. Also, with electrocautery which is more effective and has fewer recurrences (14.5% vs. 35.1%) than chemical cauterization and applying tranexamic acid that promotes hemostasis in 78% of patients, versus 35% and 31% respectively in patients treated with oxymetazoline and nasal packing. Furthermore, nasal packing can be applied with non-absorbable materials, e.g. petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel), Foley catheter, balloons (Rapid-Rhino), absorbable materials, e.g. nasal tampon (Nasopore), and with newer hemostatic materials which are more effective and with fewer complications, e.g. hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan) and fibrin glue. Moreover, epistaxis can be achieved with endoscopic ligation of arteries, mainly SPA, which is more effective than conventional nasal packing (97% vs. 62%), and with endoscopic cauterization which is more effective than ligation. Finally, for intractable cases embolization can be applied using gelatin sponge, foam, PVA and coils with 80% success rate and comparable efficacy and complications to surgical methods. Epistaxis can be dealt with various methods depending on patient's history and available resources. Newer hemostatic agents in combination with endoscopic methods have advantages over traditional methods.

Vitamin D Levels in Chronic Rhinosinusitis in Patients With or Without Nasal Polyposis: A Systematic Review

Chronic rhinosinusitis (CRS) is a large group of heterogeneous diseases characterized by extensive inflammation of the nasal mucosa and sinuses. Vitamin D (VD), as an immunoregulatory hormone, may play an important role in the pathophysiology of CRS. The purpose of this study is to review the existing literature that correlates VD levels with CRS with or without nasal polyps. A systematic manual search was conducted in the PubMed and Google Scholar databases up to July 2023. Articles from PubMed and the first 100 articles from Google Scholar were recorded for our research. Keywords used were the following: vitamin D, chronic rhinosinusitis, and nasal polyps. Among the 134 articles retrieved, only 18 were eligible. The other 116 studies were excluded as they related VD levels with other conditions (e.g., allergic rhinitis) and for other reasons. However, we identified two more eligible records through the manual research of the above-mentioned 132 studies, and finally, 20 records were included in the current review. The review concerned case-control studies, prospective, retrospective, and cross-sectional studies. Based on our review, we concluded that CRS patients are correlated with the lowest VD levels, accompanied by increased severity of the disease, especially in those with nasal polyposis. Patients can benefit from appropriate VD supplementation, and serum VD levels should be included in the laboratory assessment of CRS. However, due to the heterogeneity of the individuals involved, more well-designed clinical trials as well as randomized clinical trials should be conducted for further validation of the above findings in the general population in the future.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study

BACKGROUND

Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours.

METHODS

In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186.

FINDINGS

Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p<0·0001) and pandemic decrease phase (2·3 [1·0-5·0]; p<0·0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515 [71·5%] of 2119; OR 1·1 [95% CI 1·0-1·3]; p=0·042), lymph node metastases (343 [9·3%] vs 264 [12·5%]; OR 1·4 [1·2-1·7]; p=0·0001), and tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006; OR 1·4 [1·1-1·7]; p=0·0039).

INTERPRETATION

Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation.

FUNDING

None.

A large thyroglossal duct cyst and its management: a case report

Thyroglossal duct cysts (TGDC) are congenital neck cysts, formed as a result of the failure of the thyroglossal duct to involute during embryogenesis and their mean size is 1.5-2.4 cm. We present a case of a 44-year-old male who presented with a history of a large anterior neck mass measuring 8.7x6x6.4 cm and causing dysphagia and mild dyspnea. After being mistaken for a goiter, a clinical diagnosis of TGDC was made based on history, clinical and radiographic findings. The patient was treated with Sistrunk's procedure. No recurrence was noted on follow-up. Thyroglossal duct cysts are generally well-defined small lesions, but even bigger ones are not linked with severe symptomatology. The larger size at presentation may increase the list of potential diagnoses and lead to diagnostic dilemmas. Every effort should be made to rule out malignancy before surgery. Sistrunk's procedure with dissection of the posterior hyoid space should be the standard of care.

Laryngopharyngeal Reflux and Olfaction Disorders. Is There Any Connection? A Scoping Review

Objectives: To review the evidence regarding olfaction in patients with laryngopharyngeal reflux. Methods:Conducting a scoping review of studies evaluating olfactory sense in patients with laryngopharyngeal reflux. Online databases were searched and studies evaluating laryngopharyngeal reflux impact on other nasal functions were excluded. Other exclusion criteria were the presence of severe nasal anatomical issues, rhinosinusitis, allergic rhinitis and nasal polyps in the study group. Results:Seven studies, between 2016 and 2019, met our inclusion criteria. Olfaction threshold was significantly lower in patients with laryngopharyngeal reflux than controls in three studies and in two of these studies, all three assessed parameters, including threshold, identification and discrimination, were significantly affected in the laryngopharyngeal reflux group. In three other studies, where the Connecticut Chemosensory Clinical Research Center test had been used, smell test scores were also statistically significantly lower in the reflux group. Finally, in a survey-based study evaluating olfaction, olfactory anomalies were positively related to gastroesophageal reflux disease and gastroparesis symptom severity. Conclusions:There is scarce evidence regarding the effect of laryngopharyngeal reflux on olfaction, but preliminary evidence shows that laryngopharyngeal reflux may cause olfactory abnormalities. Thus, olfactory abnormalities can be an additional reflux manifestation. Gastroparesis, gastroesophageal reflux disease, laryngopharyngeal reflux and Helicobacter pylori infection are factors that can potentially cause olfactory sensory disturbance.

Diagnostic accuracy of fine needle aspiration cytology in parotid gland lesions

BACKGROUND

This study aimed to estimate the fine needle aspiration cytology's (FNAC) diagnostic accuracy in differentiating neoplastic from inflammatory lesions (Q1) and malignant from their benign counterparts (Q2).

METHODS

We present a retrospective case series covering a single University Hospital and six attending head and neck surgeons over eight years (January 2011 to July 2017). We concentrated on adults with clinically suspected parotid gland lesions. We offered all patients FNAC biopsy preoperatively, and the final diagnosis was established based on the findings of the final histology. The FNAC and histology results were cross-tabulated in a 2 x 2 contingency table, from which we calculated the diagnostic accuracy, sensitivity, specificity, and positive and negative predictive values.

RESULTS

From 212 consecutive patients reviewed, and after excluding thirteen cases (8 %) of valid but non-diagnostic FNAC, 161 cases (50 females and 111 males) fulfilled set eligibility criteria. The most common diagnosis was Warthin tumors (53 patients, 34 %), followed by pleomorphic adenomas (52 patients, 33.5 %). The sensitivity and specificity of FNAC in differentiating neoplastic from non-neoplastic lesions and in segregating malignant from benign conditions were estimated to be as high as 50 % and 97 %, and 98 % and 93 %, respectively.

CONCLUSION

FNAC is moderately effective in differentiating non-neoplastic from neoplastic disease and highly accurate in selecting malignant lesions from benign ones. Although the lack of FNAC sensitivity can occasionally be problematic, it still comprises a valuable tool in salivary gland surgery. HIPPOKRATIA 2022, 26 (1):25-31.

Erythropoietin levels in children with obstructive sleep apnea

OBJECTIVE

High serum erythropoietin (EPO) levels have been reported in adult patients with obstructive sleep apnea (OSA), however there is a lack of related literature in children with OSA. The main objective of this study was to explore the potential use of EPO as a pediatric OSA biomarker by exploring the relationship between serum EPO levels and the presence of pediatric OSA.

METHODS AND MATERIALS

A prospective study was conducted on children (4-12 years old) referred for overnight PSG. Thirty (30) consecutive children with mild. 30 consecutives with moderate, and 30 consecutives with severe OSA (OSA group), as well as 30 consecutive children with AHI≤1 (non-OSA group) were recruited. Morning blood specimens after PSG studies were obtained in order to compare EPO levels.

RESULTS

Finally, 115 children included for analysis. Non-OSA group consisted of 29 children (mean age: 6.93 ± 2.10) and OSA-group of 86 children (mean age: 6.78 ± 2.53). Mean EPO values for the non-OSA and OSA groups were 5.46 ± 2.29 mIU/ml and 8.33 ± 4.10 mIU/ml respectively. OSA-group had significant higher EPO levels than non-OSA (P: 0.01) while EPO levels were significantly correlated with AHI (p < 0.001).

CONCLUSION

Our study showed that serum EPO levels of children with OSA are significantly higher than those without OSA and correlate significantly with AHI. These results suggest that EPO may be considered as a biomarker candidate for pediatric OSA. Since this may be the first study on the topic further research is needed.

Prognostic indicators in clinically node-negative malignant primary salivary tumours of the parotid: A multicentre experience

OBJECTIVES

Nodal metastasis is an important prognosticator in primary parotid cancers. The management of the clinically node-negative neck is an area lacking consensus. This study investigates the occult nodal metastasis rate, and prognostic indicators in primary parotid cancers.

MATERIALS AND METHODS

We performed a multicentre retrospective case note review of patients diagnosed and treated surgically with curative intent between 1997 and 2020. Demographic, clinic-pathological and follow-up data was recorded.

RESULTS

After exclusions, 334 patients were included for analysis, with a median follow-up of 48 months. The overall rate of occult lymph node metastasis amongst patients undergoing elective neck dissection was 22.4%, with older age, high-grade and more advanced primary tumours being associated with higher rates. On multivariable analysis, age ≥ 60 years (HR = 2.69, p = 0.004), high-grade tumours (HR = 2.70, p = 0.005) and advanced primary tumours (pT3-4, HR = 2.06, p = 0.038) were associated with worse overall survival. Occult nodal metastasis on final pathology was associated with a close-to-significant reduction in regional recurrence free survival (HR = 3.18, p = 0.076).

CONCLUSION

This large series confirms the significant occult lymph node metastasis rate in primary parotid cancer, and demonstrates the importance of primary histology, tumour grade and stage in predicting survival outcome. This data supports the use of elective neck dissection in patients with high-risk tumours.

Doctors Spreading SARS-CoV-2 Infection to Their Patients and Health Workers. What is the Likelihood of This Scenario?

Aims: In this particular study, we report our experience of eight doctors infected with SARS-CoV-2 and discuss the probability of in-hospital virus transmission to patients or the rest of the hospital personnel. The importance of PPEs is highlighted. Materials and methods:We explore the data of eight doctors who were tested positive for SARS-CoV-2 after returning from their summer vacation. More specific, we evaluated the time they spent working before they got tested after their return, the symptoms they developed and the results of their tracking through their patients and the rest of hospital workers. Results:All doctors followed their working schedule, ranging from 2-4 days after their summertime off, without knowledge of being infected. They had been keeping all suggested protection precautions, while no further virus transmission to patients and/or other healthcare workers occurred, even though they had close contact and cooperation with many of them. Conclusions:Our experience suggests that, if healthcare workers conform to established safety procedures, the likelihood of further transmission both to patients and their colleagues, even in asymptomatic state, appears to be minimal.

Agger nasi mucocele cause nasolacrimal duct obstruction and chronic dacryocystitis: clinical profile, management and outcome

Epiphora is the first symptom of acquired nasolacrimal duct obstruction (NLDO), which may be due to various causes, including paranasal sinuses and tumours of the nasal cavity. A 28-year-old male patient presented chronic dacryocystitis with left-sided epiphora. Endoscopically, a bulging of the lateral nasal wall at the left-sided agger nasi area was noted. Imaging studies (CT and MRI) revealed a left-sided giant agger nasi mucocele. An endonasal endoscopic dacryocystorhinostomy (DCR) as well as opening of the agger nasi cell with mucocele removal and anterior ethmoidectomy was performed. Based on the literature, intranasal causes have very often occurred in patients with chronic dacryocystitis, but not reported as the cause of inflammation in the mucocele of agger nasi. Identification and recognition of this endonasal rare cause of NLDO-like agger nasi mucocele entity may facilitate timely intervention and can be treated successfully with a simultaneous endoscopic DCR procedure.

Endoscopic sinus surgery outcomes in CRS: quality of life and correlations with NOSE scale in a prospective cohort study

BACKGROUND

To evaluate the impact of endoscopic sinus surgery (ESS) on clinical outcomes, quality of life (QoL) and Nasal Obstruction and Symptom Evaluation (NOSE) scale in patients with CRSwNP and CRSsNP. An additional question that needs to be investigated is whether there is a correlation between patients at the age of relapse.

METHODOLOGY/PRINCIPAL

A prospective cohort study of 150 subjects [96 males, 54 females, mean age: 51.99 ± (15.73)]. The SNOT-22 and NOSE questionnaires were used to measure the patients' QoL and their nasal blockage symptoms, respectively. Endoscopic and computerized tomography (CT) scores depicted the objective findings.

RESULTS

Following ESS, the endoscopic scale showed a significant improvement in 83.85% of patients. QoL measured with SNOT-22 improved by 78.85% and with NOSE scale by 92.10%. Also, a statistically significant correlation was found between NOSE, SNOT-22 and the Lund-Kennedy scale. Recurrence was observed in 13 patients during follow-up. There was no statistically significant correlation between age, gender, smoking and recurrence tendency. Patients with baseline SNOT-22 and NOSE scores lower than 30 typically fail to obtain a clinically meaningful benefit. Patients with a rate greater than or equal to 40 achieved a minimal clinically important difference (MCID) of 83.9% and had an average symptom reduction (RI) rate of 60.3%.

CONCLUSIONS

ESS is an important treatment option for symptomatic patients with CRSwNP and CRSsNP. Both objective and subjective measurements including QoL improved significantly, and the results stabilized at 12 to 18 months. The NOSE scale is a sensitive outcome measure in the CRS population, including subjects with and without nasal polyps. In our study, SNOT-22 and NOSE are excellent predictors of postoperative improvement.

Radiation-Induced Oral Mucositis in Head and Neck Cancer Patients. Five Years Literature Review

Backround: Radiation-induced oral mucositis consists of a series of relatively frequent side effects after head and neck cancer radiotherapy and has an adverse impact on both regular treatment process and the quality of life of patients.

OBJECTIVE

The purpose of the present review is to optimize the current management of radiation-induced oral mucositis in head and neck cancer patients.

METHODS

PubMed database research was performed on articles published since 2015 that demonstrated efficacy in the management of radiation-induced oral mucositis in head and neck cancer patients. The study selection included observational, prospective, comparative, randomized, double- blind, placebo-controlled or uncontrolled, and retrospective studies, as well as systematic reviews and metanalyses.

RESULTS

From the 931 citations obtained from the search, only 94 articles met the inclusion criteria, including mucosal protectants, anti-inflammatory agents, growth factors, and various miscellaneous and natural agents. Several methods, including both pharmacological and natural agents, have been proposed for the management of oral mucositis. In addition to the already known interventions with strong evidence, according to the Multinational Association of Supportive Care in Cancer and he International Society of Oral Oncology guidelines, further agents have been used. However, a great number of them lack clear evidence, which surely requires the design of more controlled clinical trials for a better assessment of the ideal methods.

CONCLUSION

The management of oral mucositis constitutes an active area of research. In light of these results, it is aimed to illustrate those treatment strategies that are most effective regarding the treatment approach of oral mucositis.

Honey Against Radiation-induced Oral Mucositis in Head and Neck Cancer Patients. An Umbrella Review of Systematic Reviews and Meta- Analyses of the Literature

Backround: Oral mucositis (OM) consists of a major side effect of radiotherapy (RT) in head and neck (H-N) cancer patients and natural honey is gaining more and more scientific interest due to its beneficial effects in tissue repair.

OBJECTIVE

The aim of this review is to better clarify the preventive/therapeutic role of honey in the management of OM in patients with H-N cancer undergoing RT with or without chemotherapy (CT).

METHODS

We used the PubMed database to retrieve journal articles and the inclusion criteria were only reviews and meta-analyses that illustrated the effective use of honey for either the prevention or treatment of OM in H-N cancer patients receiving either RT alone or in combination with CT.

RESULTS

Our search resulted in 92 citations, of which 12 eventually fulfilled the inclusion criteria of our study. Decreased incidence and severity of OM, extended time of occurrence of mucositis, less weight loss and less treatment interruptions were occasionally documented with conventional honey use in the included reviews and meta-analyses. In contrast to conventional honey, manuka honey proved to be weak in improving OM management in the small number of included reviews in our search.

CONCLUSION

Conventional honey might constitute a highly promising natural product against OM attracting much scientific interest due to its easy accessibility and low financial cost. Hence, the lack of studies with high evidence requires further advanced research to enhance the existing knowledge about the potential value of honey in radiation-induced OM in H-N cancer patients.

Vidian canal and sphenoid sinus: an MDCT and cadaveric study of useful landmarks in skull base surgery

PURPOSE

To present the anatomical variations of vidian canal (VC) and sphenoid sinus (SS), relative to other anatomical landmarks of skull base area, which may be helpful for safer surgical approach to this area.

MATERIALS

MDCT scans (128-row MDCT system) of 90 patients (mean age 62 years) and six cadaveric heads were studied, and the following parameters were evaluated: mean length and types of VC, distance between VC and foramen rotundum (FR) and optic canal (OC), position of the VC regarding the lateral pterygoid plate (MPTG) and petrous ICA, pneumatization of SS, position of intrasinus septum regarding ICA and OC, bone dehiscence and protrusion of ICA and OC into SS. Six cadaveric heads underwent MDCT and endoscopic dissection, and the type and length of VC were evaluated. The statistical significance was assessed using Chi-square (χ²) test. Significance level was set at p < 0.05.

RESULTS

A statistical analysis was performed between the measurements at both sides, as well as between measurements in MDCT and dissection of the six cadaveric heads. Statistically significant difference was found between right and left sides in the horizontal and vertical distances between FR and VC, as well as between VC and OC. Also, there was a statistically positive correlation between type II of VC and lateral pneumatization on the right side. There was not statistically significant difference concerning VC type and length between MDCT and dissection measurements.

CONCLUSION

Surgeons addressing skull base surgery must be familiar with the anatomical and positional variations of VC and SS in the preoperative CT images so as to avoid serious complications during surgery.

Evaluation of quality of life outcomes following palliative radiotherapy in bone metastases: A literature review

PURPOSE

To assess the quality of life (QoL) following palliative radiotherapy (RT) in patients with painful bone metastases.

METHODS

A literature search limited to English-written publications was carried out, through the Cochrane Central Register of Controlled Trials (November 2018), OvidSP and PubMedCentral (1940-November 2018) databases. Subject headings and keywords included "quality of life"(QoL), "bone metastases", "palliative therapy", "pain" and "radiotherapy". Original articles, literature reviews, trials and meta-analyses revealing alterations in QoL post-RT using ratified measuring tools were examined. Studies referring to other types of metastases (e.g. brain metastases), or to other types of palliative therapy (e.g. the use of bisphosphonates alone), or focusing only on pain, or even reporting QoL only before or only after the use of RT were excluded.

RESULTS

Twenty four articles were selected from a total of 1360 articles. Seven trials proceeded to patients' randomization. The most commonly used tool to evaluate QoL was EORTC, followed by Brief Pain Inventory (BPI) and Edmonton Symptom Assessment System (ESAS) questionnaires. All studies showed improvement in symptoms and functional interference scores after RT. The QoL between responders (Rs) and non-responders (NRs) has been juxtaposed in 10 studies. Rs had a significant benefit in QoL in comparison with the NRs.

DISCUSSION

Palliative radiotherapy in painful bone metastases improves Rs' QoL.

Bilateral Tapia's syndrome secondary to cervical spine injury: a case report and literature review

A 24-year-old man presented with bilateral Tapia's syndrome (TS) after a traumatic cervical spine injury, manifested by apraxia of the hypoglossal and recurrent laryngeal nerves. The initial presentation was a profound inability to maintain upper respiratory airway patency due to bilateral vocal cord paralysis, accompanied by impairment of swallowing and loss of speech. The diagnosis was based on clinical grounds and verified by endoscopic laryngoscopy. A C7 corpectomy was performed for stabilizing the cervical spine, while conservative treatment with steroids was reserved for the TS. Over the following six months, there was complete resolution of the symptoms.

Utilizing Yoga in Oncologic Patients Treated with Radiotherapy: Review

Purpose:

Several trials on noncancer population indicate that yoga is associated with meaningful clinical effects. This study evaluated the physical and psychosocial outcomes of yoga in oncologic patients treated with radiotherapy.

Methods:

We focused on a research through Cochrane Register of Controlled Trials (CENTRAL), BioMed Central, and MEDLINE studies up to May 2017.

Results:

Yoga was found to have a substantial benefit in cancer patients’ distress, anxiety, and depression. It also demonstrated a moderate impact on fatigue and emotional function and a small and insignificant effect on functional well-being and sleep disturbances. As far as the effects on psychological outcomes are concerned, there was insufficient evidence.

Conclusions:

This systematic review of randomized controlled trials showed that yoga has strong beneficial effects on oncologic patients’ quality of life. Results of the current review must be interpreted with caution due to the relative small sample sizes of most of the included studies, while a prospective randomized study stands in need for the confirmation of our results.

Subcutaneous emphysema to the head and neck: an unlikely traumatic origin

Subcutaneous emphysema to the neck represents a rare entity mainly derived from iatrogenic and traumatic origin. We report a case of a subcutaneous emphysema resulted from an intraoral injury aiming to emphasise the significance of precise medical history to identify an unlikely mechanism. A 40-year-old female patient was presented with subcutaneous emphysema extending from the region underneath the left eye up to the submandibular area of the neck. The patient complained of painful, swollen neck. The patient mentioned that the symptoms began after an intraoral injury accidentally caused by the use of a high-pressure water jet device meant for car wash. The patient was managed conservatively and was discharged after 2 days. This case highlights the urgency for clinical suspicion for unlikely mechanisms. Moreover, the manufacturer companies should alert and give official warning for the contingency of injury due to incorrect or careless usage.

Addressing the post-irradiation hypothalamic-pituitary endocrine abnormalities of brain tumors in pediatric patients

PURPOSE

Hypothalamic-pituitary axis is susceptible to radiotherapy, causing endocrine disorders to childhood cancer survivors. We conducted a systematic review in order to assess the radiation-induced toxicity that leads to hormone secretion abnormalities and their severity in children with brain tumors.

METHODS

The data were collected by relevant studies on PubMed and EMBASE. Articles up to December 2016 were included. We selected studies which focused on children patients (<18 yr old) with brain tumors treated with radiotherapy and the consequences for their endocrine system.

RESULTS

Growth hormone (GH) deficiency was the most common post-irradiation abnormality among children cancer survivors, followed by gonadotrophin (GT), thyroid stimulating hormone (TSH), corticotropin (ACTH) and prolactin (PRL) disorders.

CONCLUSIONS

The age of the patient, total radiotherapy dose, number of fractions, fraction size and the duration of treatment seem to determine the severity of these disturbances.

How can we effectively address the paraneoplastic dermatomyositis: Diagnosis, risk factors and treatment options

PURPOSE

Dermatomyositis (DM) represents an auto-immune inflammatory myopathy. In this review, we analyzed the incidence of DM as a clinical manifestation highlighting the peculiar clinical and treatment characteristics of this disease when occurring in the context of different malignancies.

METHODS

A systematic literature review was performed based on database search in PubMed/Medline and included English articles until December 2016.

RESULTS

In up to 20% of cases DM appears as a paraneoplastic syndrome associated with multiple malignancies such as ovarian, breast, prostate, lung, nasopharyngeal and colorectal cancer, and non-Hodgkin lymphomas. It can be presented either before, in the time, or after cancer diagnosis. Systemic sclerosis and mixed connective-tissue disease represent common coinciding disorders. Particular caution should be given in the radiotherapy because the microvascular endothelial radiation damage and autoimmune inflammatory collagen vascular disease caused by DM may be additive. There is a higher risk of late toxicity in the presence of other concurrent vascular diseases, including diabetes, hypertension or administration of chemotherapy. Prednisone represents the first-line treatment option but immunosuppressive drugs such as azathioprine and methotrexate may also be incorporated in the therapeutic armamentarium especially when DM is associated with malignancy. Intravenous immunoglobulin could be a promising alternative in prednisone-resistant cases. The effectiveness of therapies with antigen-specific agents such as monoclonal antibodies is currently under investigation.

CONCLUSIONS

Timely diagnosis coupled with a treatment plan focused on muscular endurance and improvement of skin lesions and other symptoms offer a favorable response to therapy along with the achievement of a higher quality of life for these patients.

Brucella Melitensis As Causative Agent for Neck Abscess in an Endemic Area

Background:

Brucellosis, a zoonotic disease, is very common in the Mediterranean basin and a major concern in livestock areas. We present a rare case of a Brucella-caused abscess in the neck of a stock-breeder in an endemic Greek area.

Case Report:

A 39-year-old male, living in the rural area of Thessaly, presented with a mass in the left area of his neck. Clinical examination and imaging tests revealed an abscess in the left sternocleidomastoid muscle. Sampling of the abscess by fine-needle aspiration yielded inflammatory fluid (17x10³ cells/μL). Molecular sequencing (16S rRNA polymerase chain reaction) performed directly in the clinical sample identified the presence of Brucella melitensis within 24 hours after material sampling. The microorganism was isolated in agar media four days later. The Rose-Bengal test was negative, while the Brucellacapt test showed titer 1/320. Given the results obtained with these molecular techniques, the patient was offered treatment with streptomycin (1 g for 3 weeks) and oral doxycycline (100 mg twice daily for 6 weeks), concurrently.

Conclusion:

In areas endemic for brucellosis, the investigation of a patient with a neck abscess should include Brucella spp. among possible causative agents.

Intraoperative radiation therapy (IORT) in head and neck cancer: A systematic review

BACKGROUND

Multimodality therapy constitutes the standard treatment of advanced and recurrent head and neck cancer. Since locoregional recurrence comprises a major obstacle in attaining cure, the role of intraoperative radiation therapy (IORT) as an add-on in improving survival and local control of the disease has been investigated. IORT allows delivery of a single tumoricidal dose of radiation to areas of potential residual microscopic disease while minimizing doses to normal tissues. Advantages of IORT include the conformal delivery of a large dose of radiation in an exposed and precisely defined tumor bed, minimizing the risk of a geographic miss creating the potential for subsequent dose reduction of external beam radiation therapy (EBRT). This strategy allows for shortening overall treatment time and dose escalation. The aim of this review is to summarize recent published work on the use of IORT as an adjuvant modality to treat common head and neck cancer in the primary or recurrent setting.

METHODS

We searched the Medline, Scopus, Ovid, Cochrane, Embase, and ISI Web of Science databases for articles published from 1980 up to March 2016.

RESULTS

Based on relevant publications it appears that including IORT in the multimodal treatment may contribute to improved local control. However, the benefit in overall survival is not so clear.

CONCLUSION

IORT seems to be a safe, promising adjunct in the management of head and neck cancer and yet further well organized clinical trials are required to determine its role more precisely.

In the era of endoscopic sinus surgery, is there still a place for the Caldwell-Luc procedure?

In the era of endoscopic sinus surgery, is there still a place for the Caldwell-Luc procedure? In this report, we present evidence in favor of the Caldwell-Luc approach to the maxillary antrum in selected cases where endoscopic techniques are inadequate to allow full resolution of the problem. Although this procedure is not as popular as it was in the past, its role in the management of benign paranasal sinus diseases is still important. We focus in particular on use of the Caldwell-Luc procedure for conditions such as fungal mycetoma, foreign body removal, empyema, and benign nasal tumours in areas that are not fully accessible by endoscopy alone. Advantages of this technique are its safety and simplicity; no special instrumentation is necessary. It can be performed with surgical equipment widely available in operating rooms in Greece and elsewhere.

The combined use of two RapidRhino packs instead of anteroposterior packing for the control of severe epistaxis

Epistaxis is a common ear, nose, and throat emergency, and severe cases are traditionally controlled by the placement of anteroposterior nasal packing. In this article, a way of controlling severe epistaxis with the combination of two RapidRhino packs is described. Although not always successful, it is a technique that in the majority of patients can control severe bleeding faster, easier, with decreased pain, and increased patient comfort, compared to the traditional anteroposterior nasal packing.

Hypomethylation along with increased H19 expression in placentas from pregnancies complicated with fetal growth restriction

The expression of imprinted genes is regulated by epigenetic modifications, such as DNA methylation. Many imprinted genes are expressed in the placenta and affect nutrient transfer capacity of the placental exchange barrier. The H19 gene is abundantly expressed by the human placenta and is implicated in the pathogenesis of congenital growth disorders such as Beckwith-Wiedemann (BWS) and Silver-Russell (SRS) syndromes. The aim of this study was to investigate the role of DNA methylation on H19 transcription and imprinting, in the pathophysiology of fetal growth restriction (FGR). Thirty one and 17 placentas from FGR-complicated and normal pregnancies were collected, respectively. We studied gene transcription, genotyping and methylation analysis of the AluI H19 on exon 5 polymorphism. Placental expression levels of H19 were significantly increased in the FGR group. The H19 mRNA levels were similar between normal placental samples that demonstrated loss and maintenance of imprinting. Placentas from growth-restricted pregnancies had lower methylation levels compared to normals, in the H19 promoter region. We have demonstrated an increased H19 transcription in the FGR group of placentas. The hypomethylation of the H19 promoters is compatible with the aberrant expression. The association of these two findings is reported for the first time in placental tissues, however, its significance remains unknown. Whether the results of this study represent an adaptation of the placenta to hypoperfusion, or they are part of FGR pathophysiology has to be further investigated.

Evaluation of anatomical variation of the crista galli using computed tomography

Pneumatization of the crista galli is a recognized incidental finding on computed tomography (CT), usually with little relevance to the clinical picture. There are, however, notable exceptions: congenital midline nasal defects including nasal dermoids have been seen to track through or near the crista galli. Mucocele development has also been seen. This study aimed to evaluate the variation in crista galli morphology and pneumatization and assess whether specific morphologies occur. A retrospective observational study was undertaken between November 2007 and January 2008. Using coronal and axial reconstructed CT views, images of the head in the region of the paranasal sinuses were assessed. Variations in the crista galli were classified according to their position relative to the cribriform plate and to the degree of pneumatization. Computed tomography findings of the morphology of the crista galli in 99 patients were reviewed and a classification system derived from the findings. Three variations of the position of the base of the crista galli were defined. In 28.3% of subjects the base of the crista galli did not extend below the level of the cribriform plate. In 63.6%, the crista galli extended less than 50% of its height below the cribriform plate and in 8.1% of the scans the crista galli extended more than 50% of its height below the cribriform plate. Pneumatization was noticed in 14.1% of the scans. Our results demonstrate the variation that occurs in the morphology and pneumatization of the crista galli. We hope this knowledge might be of help in preoperative planning of surgical approaches to sites of disease involving the crista galli.

Lidocaine spray versus tetracaine solution for monopolar submucosal diathermy for inferior turbinate hypertrophy

OBJECTIVE

To compare the efficacy of lidocaine spray 10% to tetracaine 2% solution, as a local anaesthetic for patients undergoing monopolar submucosal diathermy of the inferior turbinate.

METHODS

A prospective study was conducted on 48 patients undergoing submucosal diathermy of the inferior turbinate. Patients were randomly assigned to receive tetracaine 2% solution (24 patients) or to receive lidocaine spray 10% (24 patients). Patients were asked to evaluate the severity of pain during the procedure using a visual analogue scale. Patient data, pain scores, and potential complications were assessed statistically.

RESULTS

The tetracaine group had significantly lower mean pain scores compared to the lidocaine group: 2.29 vs. 3.04 (p < 0.001). There were no complications or side effects from tetracaine.

CONCLUSION

Tetracaine 2% solution applied locally is an easy, safe, inexpensive, and effective analgesia for submucosal diathermy for inferior turbinate hypertrophy.

Epiglottis reshaping using CO2 laser: a minimally invasive technique and its potent applications

Laryngomalacia (LRM), is the most common laryngeal abnormality of the newborn, caused by a long curled epiglottis, which prolapses posteriorly. Epiglottis prolapse during inspiration (acquired laryngomalacia) is an unusual cause of airway obstruction and a rare cause of obstructive sleep apnea syndrome (OSAS). We present a minimally invasive technique where epiglottis on cadaveric larynx specimens was treated with CO2 laser. The cartilage reshaping effect induced by laser irradiation was capable of exposing the glottis opening widely. This technique could be used in selected cases of LRM and OSAS due to epiglottis prolapse as an alternative, less morbid approach.

Successful term pregnancy in a patient with Wegener's granulomatosis: case report and literature review

OBJECTIVE

To present a case of successful term pregnancy in a patient with known Wegener's granulomatosis (WG).

DESIGN

Case report.

SETTING

University Hospital, Department of Obstetrics and Gynecology.

PATIENT(S)

A 22-year-old primigravida pregnant woman with a history of WG diagnosed 5 years before.

INTERVENTION(S)

The patient was treated with corticosteroids and azathioprine throughout pregnancy, and cyclophosphamide was added postpartum.

MAIN OUTCOME MEASURE(S)

The disease was in partial remission at the onset of pregnancy, but two relapses occurred, at 33 weeks' gestation and 15 days after delivery. A 3150-g healthy boy was delivered at 37 weeks' gestation.

CONCLUSION(S)

Pregnancy in patients with WG requires preconceptional planning, careful clinical management, and vigorous treatment of active disease. There are 36 cases of WG in pregnancy reported in the literature. Owing to this rarity, the management is individualized and the pregnancy outcome is variable. Antenatal management and therapeutic options are discussed and a short review of the literature is presented.

Mumps Epidemic Among Young British Citizens on the Island of Crete

BACKGROUND

Mumps is an infectious disease, occurring rarely in many countries including Greece, where approximately 50 cases are reported each year. In Crete, Greece's biggest island, an average number of four cases are reported annually.

PATIENTS AND METHODS

The study population consists of all patients hospitalised because of mumps in our clinic. Clinical, laboratory and serological confirmation of the disease has been performed.

RESULTS

During the tourist summer periods of 2004 and 2005, 39 patients with mumps have been hospitalized in our clinic in Crete. All patients but one were young tourists from Britain. The patients presented with parotid gland swelling and fever and some developed complications of the disease as well.

CONCLUSION

The above findings are consistent with the mumps epidemic, now occurring in the UK. The disease is spreading among the Greek population as well, since six cases have been reported. This study investigates the reasons for this epidemic, focusing on the role of MMR vaccination.

Otitis media with effusion: what parents want to know

Introduction:

Otitis media with effusion is a common condition of childhood. The development of an information leaflet for parents of children with the condition, and its impact on clinical management, have not previously been examined.

Patients and methods:

Eighteen doctors and 38 parents assessed the content of an information leaflet on otitis media with effusion, by applying two rounds of the modified Delphi technique. A qualitative assessment of content items was also performed.

Results:

From the 23-item list used in the first assessment round, four items had a low doctor–parent agreement and seven were excluded. Differences were also noticed in comments on the value of such leaflets, with parents being more positive about the value of leaflet distribution.

Conclusion:

During the consultation, doctors may not tell parents what they want to know, especially regarding daily care of their child. An information leaflet, developed using the Delphi technique, can help reduce this discrepancy and increase parents' satisfaction.