A. Bozzato

Sialoscopy in Cases of Unclear Swelling of the Major Salivary Glands

OBJECTIVE: Sialoscopy has developed into an important diagnostic and therapeutic tool for diseases of the major salivary glands. STUDY DESIGN AND SETTING: We evaluated 103 patients with chronic swelling of the major salivary glands. Routine diagnostic measures revealed no clear diagnosis. The findings of 109 sialoscopies are described. A semi-rigid endoscope (with a diameter of 1.1 mm and 2 integrated working channels) was used for sialoscopy, 51.5% of the cases in Warthons duct and 48.5% in Stensens duct. RESULTS: Pathologic findings resulted in 83.0% of the submandibular and in 96% of the parotid ducts. Obstruction neither due to sialolithiasis nor stenosis was observed in 56.3%, whereas sialolithiasis was observed in 20.3% of the patients. In 36 (35%) patients, an interventional sialoscopy was performed. CONCLUSIONS: In cases of invisible salivary duct obstruction, especially in those with low mineralized calculi, strictures, stenoses, or postinflammatory changes, sialoscopy gives immediate and direct information about causal pathologies. Moreover, further therapy can be planned within the same procedure. EBM RATING: C

Combined endoscopic and transcutaneous approach for parotid gland sialolithiasis: indications, technique, and results.

OBJECTIVE: Despite all the advances of minimally invasive surgery, refractory stones remain in 10 to 20 percent of all cases of parotid gland sialolithiasis, and persistence of the symptoms makes removal of the gland inevitable. In some of these cases, however, it may be possible to conserve the gland using a combination of endoscopic and transcutaneous procedures. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Nine patients treated with a combined endoscopic transcutaneous operation were evaluated. During this procedure, the stone is removed through a skin incision under endoscopic guidance. Indications were sialolithiasis refractory to treatment (n = 5), sialolithiasis with complications (n = 2), contraindications to primary minimally invasive surgery (n = 1), and primary treatment (n = 1). In seven cases, the stones were extracted. Simultaneous resection of a sialocele was carried out in one case, and simultaneous resection of a saliva-cutaneous fistula was carried out in another. A stent was inserted in 66.7 percent of the cases. RESULTS: Treatment was successful in 88.9 percent of the patients. All of these patients were free of stones and symptoms, and glandular function was maintained both clinically and on ultrasound assessment. Complete parotidectomy had to be carried out in one case because it was not possible to reconstruct the duct system. CONCLUSION: The combined operation offers a further option for gland-conserving treatment in cases with obstructive salivary gland disease, especially sialolithiasis. At present, it is indicated for cases that are resistant to treatment after sialendoscopy or extracorporeal shock wave lithotripsy. The gland resection rate can thus be further reduced.

Sonoelastography of parotid gland tumours: initial experience and identification of characteristic patterns.

ObjectivesThe aim of this study was to investigate B-mode and elastographical ultrasound criteria capable of differentiating between benign and malignant parotid tumours and to define characteristic elastographical patterns for pleomorphic adenomas and Warthin’s tumours.MethodsFifty-seven patients with parotid gland tumours were examined using a combination of B-mode and elastographic ultrasounds. The data acquired were analysed retrospectively by two experienced ultrasound operators to identify specific sonographical features of benign and malignant lesions. Additionally, elastographical patterns were defined and analysed for their specificity.ResultsA blurred margin proved to be the only significant criterion in B-mode ultrasound capable of differentiating between malignant and benign tumours. The garland sign was defined as an elastographical pattern found significantly more frequently in malignant tumours, improving sonographical prediction of the benign or malignant nature of a parotid lesion. A logistic regression model was developed that achieved a correct prediction in 87.7% of cases. A “dense core” sign was also specifically defined for pleomorphic adenomas and a “half-half” sign for Warthin’s tumours.ConclusionsElastography is an innovative and powerful diagnostic tool that can improve the sonographical examination of parotid gland tumours by revealing easily recognised and characteristic patterns of tissue distribution.Key Points• Elastography can help differentiate benign from malignant parotid tumours during parotid ultrasound.• The elastographical “garland sign” is more frequent in malignant than benign parotid tumours.• Pleomorphic adenomas show an elastographical “dense core sign”.• Warthin’s tumours show an elastographical “half-half sign”.• Parotid cysts show an elastographical “bull’s-eye sign”.

Diagnosis and gland-preserving minimally invasive therapy for wharton's duct stenoses†

The management of stenoses of Whartons duct has so far been little investigated or systematized. The development of minimally invasive treatment methods, including sialendoscopy, has made preservation of gland function possible.

First experience with a new titanium clip stapes prosthesis and a comparison with the earlier model used in stapes surgery

The aim of the study was to gain the first clinical experience with a new titanium clip prosthesis in stapes surgery, and to compare this model with its predecessor. We placed particular emphasis on the practicability of fixing the prosthesis to the long process of the incus and on the postoperative improvement in hearing.

Anaphylactic reaction following administration of nose drops containing benzalkonium chloride.

We describe a case of anaphylactic reaction in a 46-year-old female post application of decongestant nose drops containing benzalkonium chloride (BAC). With some latency, the patient complained of cough, dyspnea, sensation of heat, croakiness and pruritus. Since she showed all of these symptoms, typical of an anaphylactic reaction, we proceeded some weeks later with a prick test with solutions containing BAC, a cationic surfactant commonly used as an antibacterial preservative in many medical solutions. The prick test was positive, confirming the assumption of a hypersensitive reaction to BAC.

Vitamin C as contrast agent in diagnosis of salivary duct obstruction

In obstructive diseases of the salivary glands ultrasound is routinely used. In obstructive sialadenitis of the parotid and submandibular glands, diagnostic assessment of the origin and location of impediment is sometimes difficult. We studied sonographic visibility of the duct before and after stimulation with oral ascorbic acid (Vitamin C), the diagnosis compared to sialoendoscopy. In 43 patients with obstructive salivary gland diseases ultrasound examination of the parotid and submandibular glands was carried out before and after oral ascorbic acid stimulation. Before stimulation the duct system was depicted in 27 patients (63%). After ascorbic acid stimulation the duct system became visible in now 41 patients (95%). Application of ascorbic acid as part of ultrasound assessment improves diagnostic capabilities in patients with obstructive salivary gland diseases.

Computer Aided Diagnosis of Parotid Gland Lesions Using Ultrasonic Multi-Feature Tissue Characterization

In this article, an ultrasound based system for computer aided characterization of biologic tissue and its application to differential diagnosis of parotid gland lesions is proposed. Aiming at an automated differentiation between malignant and benign cases, the system is based on a supervised classification using tissue-describing features derived from ultrasound radio-frequency (RF) echo signals and image data. Standard diagnostic ultrasound equipment was employed to acquire ultrasound RF echo data from parotid glands of 138 patients. Lesions were manually demarcated as regions-of-interest (ROIs) in the B-mode images. Spectral ultrasound backscatter and attenuation parameters are estimated from diffraction corrected RF data, yielding spatially resolved parameter images. Histogram based statistical measures derived from the parameters distributions inside the ROI are used as tissue describing features. In addition, texture features and shape descriptors are extracted from demodulated ultrasound image data. The features are processed by a maximum likelihood classifier. An optimal set of 10 features was chosen by a sequential forward selection algorithm. The classifiers performance is evaluated using total cross validation and receiver operating characteristic (ROC) analysis. As a reference method, postoperative pathohistologic analysis was conducted and proved malignancy or prospective malignancy in 51 patients. The classification using the proposed system yielded an area under the ROC curve of 0.91, proving significant potential for differentiating between malignant and benign parotid gland lesions.

Effect of 3q oncogenes SEC62 and SOX2 on lymphatic metastasis and clinical outcome of head and neck squamous cell carcinomas

Chromosome 3q26 amplification represents a frequent alteration in head and neck squamous cell carcinomas (HNSCCs). Overexpression of 3q26 encoded genes SEC62 and SOX2 was detected in various cancers, including HNSCCs, indicating their potential function as oncogenes. In our study, we elucidated the function of SEC62 and SOX2 in HNSCC patients, with a main focus on their effect on lymphatic metastasis and patient survival. We analyzed SEC62 and SOX2 expression in tissue specimens from 65 HNSCC patients and 29 patients with cervical cancer of unknown primary (CUP); a higher SEC62 and lower SOX2 expression was observed in the lymph node metastases from HNSCC patients compared with the respective primary tumor. Lymph node metastases from CUP patients showed higher SEC62 and lower SOX2 expression compared with lymph node metastases from HNSCC patients. When proceeding from the N1 to the N3 stage, SEC62 expression in the lymph node metastases showed an increase and SOX2 expression showed a decrease. Moreover, both genes showed a highly significant relevance as prognostic biomarkers, with the worst prognosis for patients with high SEC62 and low SOX2 expression levels. In functional analyses, knockdown of SEC62 resulted in an inhibition of HNSCC cell migration while, conversely, SEC62 and SOX2 overexpression stimulated cell migration. Taken together, our study showed that the expression of the 3q oncogenes SEC62 and SOX2 affects lymphatic metastasis and cell migration in HNSCC and CUP patients and has a high prognostic relevance in these diseases.

Weichteilnavigation im Kopf- Hals-Bereich und navigierte Fremdkörperentfernung

BACKGROUND Soft tissue navigation has traditionally been neglected in computer-aided surgery (CAS) because of unpredictable margins of error. In our study, we examined clinical cases in which standard CAS was applied in soft tissue surgery in the head and neck region. Its extended applicability, margins of error, and general performance are described and discussed. MATERIALS AND METHODS CAS was applied in surgical procedures for six patients. Five patients had foreign bodies in the head and neck region, and one patient displayed uncertain cervical lymph node enlargement. An optoelectrical navigation system (VectorVision(2), BrainLAB) was used in all cases. RESULTS Using CAS, 10 out of 11 total foreign bodies were identified. Only one glass splinter attached to the eyeball could not be detected by the navigation system. One glass splinter that was deeply buried within the sphenoid bone was easily found but was left untouched. The parapharyngeal lymph node was identified and extracted in a minimally invasive transpalatinal approach. CONCLUSIONS Soft tissue navigation was successfully applied in all but one case; the success was due to the altered demands in soft tissue navigation as opposed to skull-base surgery. Easy identification of foreign bodies and lymph nodes was possible in the soft tissues of the head and neck, with an acceptable margin of error.