Bee See Goh

Stem cell genes are poorly expressed in chondrocytes from microtic cartilage

OBJECTIVES This study was aimed to see the difference between chondrocytes from normal cartilage compared to chondrocytes from microtic cartilage. Specific attentions were to characterize the growth of chondrocytes in terms of cell morphology, growth profile and RT-PCR analysis. STUDY DESIGN Laboratory experiment using auricular chondrocytes. METHODS Chondrocytes were isolated from normal and microtic human auricular cartilage after ear reconstructive surgeries carried out at the Universiti Kebangsaan Malaysia Medical Centre. Chondrocytes were cultured in vitro and subcultured until passage 4. Upon confluency, cultured chondrocytes at each passage (P1, P2, P3 and P4) were harvested and subjected to growth profile and gene expression analyses. Comparison was made between the microtic and normal chondrocytes. RESULTS For growth profile analysis cell viability did not show significant differences between both samples. There are no significance differences between both samples in terms of its growth rate, except in passage 1 where microtic chondrocytes were significant lower in their growth rate. Population doubling time and total number of cell doubling of all samples also did not show any significant differences. Gene expression is measured using Real Time-Reverse Transcriptase Polymerase Chain Reaction (RT-PCR). There is no significant differences in the expression of collagen type I, collagen type II, collagen type X, aggrecan core protein, elastin and sox9 genes in both samples. There are significant lower in the expression of sox2, nestin, BST-1 and OCT-4 gene in microtic chondrocytes compared to the normal chondrocytes. Stem cells markers are included in this study as stemness in cells may imply a greater proliferative potential and plasticity in vitro. CONCLUSION Chondrocytes from microtic samples have the same properties as chondrocytes from normal samples and hold promises to be used as a starting material in the reconstruction of the external ear in future clinical application. The reduction in sox2, nestin, BST-1 and OCT-4 gene expression in microtic samples could be the possible cause of the arrested development of the external ear.

Supraglottoplasty for Laryngomalacia: Who Will Benefit?

OBJECTIVE Laryngomalacia is the most common cause of neonatal and infantile stridor. The aim of this study was to assess the outcome of surgical intervention in children with laryngomalacia. METHODS Between January 1998 and December 2008, 15 children with laryngomalacia underwent surgical intervention at the Universiti Kebangsaan Malaysia Medical Centre, from which only eight case notes were available. These were retrospectively reviewed for demographic data, symptoms, comorbidities, operative technique, postoperative recovery, complications, length of hospital stay including intensive care unit (ICU) care, and resolution of symptoms. RESULTS Patients consisted of seven males and one female. One patient underwent three procedures, resulting in a total of 10 procedures for this study. The mean age was 15.6 months (range: 2-39 months). The most common indication for surgery was severe stridor resulting in failure to thrive. Intra-operatively, all patients were found to have short aryepiglottic folds, and four also had redundant arytenoid mucosa. Supraglottoplasty was performed in 10 patients: three by cold instruments and seven by laser. Successful extubation was achieved in the operating theatre in eight patients while the other two were extubated in the ICU on the same day. Postoperative ICU nursing was required in six patients: three for up to 3 days, and three for longer periods because of medical problems. Resolution of stridor was complete in four patients, partial in one, and no difference in five. Two patients defaulted follow-up. There were no postoperative complications from the procedures. The average length of follow-up was 15 weeks (range: 12 days to 7 years). CONCLUSION Supraglottoplasty remains an effective method to treat severe laryngomalacia. Patients who will benefit most are those with severe laryngomalacia that is uncomplicated by neurological conditions or multiple medical problems. In our institution, early extubation is the norm, and a significant number of patients can be nursed in the normal wards and be discharged within 48 hours of the procedure.

Chondrogenesis of human adipose derived stem cells for future microtia repair using co-culture technique

Abstract Conclusion: In conclusion, these result showed HADSCs could differentiate into chondrocytes-like cells, dependent on signaling induced by TGF-β3 and chondrocytes. This is a promising result and showed that HADSCs is a potential source for future microtia repair. The technique of co-culture is a positive way forward to assist the microtia tissue. Objective: Reconstructive surgery for the repair of microtia still remains the greatest challenge among the surgeons. Its repair is associated with donor-site morbidity and the degree of infection is inevitable when using alloplastic prosthesis with uncertain long-term durability. Thus, human adipose derived stem cells (HADSCs) can be an alternative cell source for cartilage regeneration. This study aims to evaluate the chondrogenic potential of HADSCs cultured with transforming growth factor-beta (TGF-β) and interaction of auricular chondrocytes with HADSCs for new cartilage generation. Methods: Multi-lineages differentiation features of HADSCs were monitored by Alcian Blue, Alizarin Red, and Oil Red O staining for chondrogenic, adipogenic, and osteogenic differentiation capacity, respectively. Further, HADSCs alone were culture in medium added with TGF-β3; and human auricular chondrocytes were interacted indirectly in the culture with and without TGF-βs for up to 21 days, respectively. Cell morphology and chondrogenesis were monitored by inverted microscope. For cell viability, Alamar Blue assay was used to measure the cell viability and the changes in gene expression of auricular chondrocyte markers were determined by real-time polymerase chain reaction analysis. For the induction of chondrogenic differentiation, HADSCs showed a feature of aggregation and formed a dense matrix of proteoglycans. Staining results from Alizirin Red and Oil Red O indicated the HADSCs also successfully differentiated into adipogenic and osteogenic lineages after 21 days. Results: According to a previous study, HADSCs were strongly positive for the mesenchymal markers CD90, CD73, CD44, CD9, and histocompatibility antigen. The results showed HADSCs test groups (cultured with TGF-β3) displayed chondrocytes-like cells morphology with typical lacunae structure compared to the control group without TGF-β3 after 2 weeks. Additionally, the HADSCs test groups increased in cell viability; an increase in expression of chondrocytes-specific genes (collagen type II, aggrecan core protein, SOX 9 and elastin) compared to the control. This study found that human auricular chondrocytes cells and growth factor had a positive influence in inducing HADSCs chondrogenic effects, in terms of chondrogenic differentiate of feature, increase of cell viability, and up-regulated expression of chondrogenic genes.

Numb chin syndrome: an ominous sign of mandibular metastasis

A 51-year-old woman a known case of stage 2 breast carcinoma in 2006 and underwent left mastectomy performed in the same year presented with bilateral lower limb pain suggestive of spinal pathology, and left chin numbness, both of 2 weeks’ duration. Examination revealed left mandibular hypoesthesia without any other sign or symptoms. Orthopantomogram was unremarkable apart from mild alveolar bone expansion at tooth 36 area, which was extracted 3 months earlier. Subsequently, a full-body positron emission tomography contrast enhanced computer tomography revealed hypermetabolic lesions of her axial (excluding skull) and appendicular skeleton. In the head and neck region, left mandibular foramen and oropharynx bilaterally showed increased metabolism suggestive of tumour metastasis. The diagnosis was numb chin syndrome secondary to mandibular metastasis. Apart from supportive treatment, she was started on palliative chemotherapy and radiotherapy. At the time of discharge, there were no active complaints other than the aforementioned hypoesthesia.

A Toddler with Rhabdomyosarcoma Presenting as Acute Otitis Media with Mastoid Abscess.

Rhabdomyosarcoma (RMS) is a malignant tumor which involves the striated muscle, and it is most common in the pediatric age group. Usually, children with RMS present with persistent ear discharge, aural polyp and hearing loss which are similar to the symptoms seen in chronic otitis media (COM).[1,2] This similarity with COM often delays the diagnosis. The histological diagnosis of RMS is always a challenge because there are many other conditions which exhibit similar characteristic features such as an aural polyp.[3] We discussed an unusual case of RMS in a 15-month-old girl who presented with acute otitis media (AOM) and mastoid abscess. The biopsy of the aural polyp confirmed the diagnosis. A 15-month-old girl presented with a history of right ear discharge for 1 month. Otoscopic examination was performed, and a polyp was observed. The tissue was sent for histopathological examination, and the report suggested pyogenic granuloma. Subsequently, she developed right facial asymmetry and mastoid swelling for 3 days. Clinically, the child was active, despite high-grade temperature at 38.7°C. There was a right mastoid swelling which was tender, inflamed, and fluctuant. Otoscopic examination revealed polypoidal tissue obscuring the view of the tympanic membrane. There was House-Brackmann Grade IV right facial nerve paresis. Diagnosis of right AOM with mastoid abscess was made. A high-resolution computed tomography of temporal showed extensive bony erosion of the right tegmen tympani and cortex of mastoid with soft tissue filling up the ear canal and middle ear [Figure 1]. A ring enhancing collection was observed in the soft tissue adjacent to the mastoid, and it was suggestive of an abscess formation. No hearing assessment was performed as the patient was admitted after office hours and audiology services were unavailable. She underwent examination under anesthesia and right cortical mastoidectomy with drainage of postauricular abscess which communicated with the external ear canal. Figure 1 High-resolution computed tomography temporal of the patient showed extensive bony erosion of the right mastoid (black arrow) and abscess formation at the soft tissue adjacent to the mastoid (white arrow). Intra-operatively, the mastoid cortex was noted to be breached with unhealthy tissue overlying it. There was extensive soft tissue filling up the entire mastoid cavity, antrum, middle ear, and external ear canal. The proximal part of the vertical portion of the facial nerve was exposed by the polypoidal tissue, and the nerve was found to be edematous. The polypoidal tissue was sent for histopathological examination. She completed 2 weeks of intravenous Ceftriaxone and 1 week of intravenous Dexamethasone. The postauricular wound did not heal well and there was new granulation tissue observed at the inferior edge of the wound. The polypoidal tissue in the ear canal also persisted despite 2 weeks of IV antibiotic. The histopathological examination confirmed the diagnosis of embryonal RMS. Immunohistochemistry staining was positive for desmin and vimentin. This explained the poor response of the disease to antibiotics. She was referred to pediatric oncology and chemotherapy was started. She recovered well and is currently in remission with normal hearing and normal facial nerve function. RMS is a family of soft tissue tumors which is associated with skeletal muscle lineage, and it usually occurs in the pediatric population. It is the most common sarcoma in the head and neck region, accounting for 40% of all sarcomas in this region. Its site includes the orbit, oral cavity, nasopharynx, infratemporal fossa, rarely middle ear cavity, and mastoid.[4] The average age of presentation and diagnosis is at 4 years.[1,2] The age of patients ranged between 1 and 8.6 years in a cohort of 14 patients.[1] In the present case, the patient was merely 15 months old, i.e., a toddler. The presenting complaints of RMS often mimic COM. The patients usually present with chronic aural discharge, hearing loss with aural polyp.[1,2] An early diagnosis is always a challenge because of the clinical features simulating COM. In this case, the patient presented with AOM complicated with facial nerve palsy and mastoid abscess. These were rare and unusual presentations. The clinical features seen in the present case was similar to a past research report which described symptoms such as bloody discharge, facial palsy, and lymphadenopathy.[1] Retroauricular mass, aural polyp, ipsilateral facial nerve palsy (tympanic facial nerve canal invasion), and cranial nerves V, VII, IX, XI, and XII palsies (intracerebral extension) are common features in extensive RMS.[2] In 2012, Vegari et al. reported a 3-year-old child with serosanguineous purulent ear discharge with aural mass for 3 weeks and biopsy revealed embryonal RMS. This showed that young children who presented with AOM and aural polyp must always be investigated carefully for malignancy, especially RMS.[5] A repeat biopsy might be needed if the initial histological result shows benign lesion as in this case. There are many other causes of aural polyp including inflammatory polyps, cholesteatoma, chronic nonspecific inflammation, abscess, and squamous cell carcinoma, with malignancies involving two out of fifty cases.[3] Nevertheless, diagnosis of RMS relies on pathological evaluation. Therefore, repetitive biopsy is crucial to reach diagnosis, especially in children with recurrent aural polyp who do not respond to treatment. Four histological subtypes have been reported, most common being embryonal, which is also the subtype in this patient; followed by alveolar, others are pleomorphic and botryoid.[4] RMS has a poor prognosis and in the earliest series reported in 1966, no case of survival was reported. The longest survival time was 22 months following presentation. Multimodal treatment includes multidrug chemotherapy with radiotherapy and/or surgery (international society of pediatric oncology protocols) and it leads to significant improvement regarding remission rates. Five-year survival rate was reported to vary between 41% and 81%.[2] Long-term follow-up is required to exclude recurrence and to recognize and treat all complications. In conclusion, RMS is a rare tumor and it is associated with high mortality rate in the pediatric group, if diagnosed late. A high index of suspicion is needed to arrive at an early diagnosis. The present case illustrated a young patient with AOM, mastoid abscess, facial palsy, and aural polyp who required repetitive biopsies for the diagnosis of RMS. We opine that early diagnosis and multimodal treatment might be essential for a favorable outcome. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.