Bulent Karci

A nasopharyngeal mass: leech in the nasopharynx.

This paper presents a case with a 4-month history of nasal obstruction and intermittent epistaxis. The cause was found to be a leech in the nasopharynx by means of endoscopic examination. Leech endoparasitism, although rare, may cause serious, even lethal, complications. A high index of suspicion of leech infestation must be entertained when faced with nasal obstruction and intermittent epistaxis in children, and should be investigated surgically as with all other foreign bodies.

Juvenile nasopharyngeal angiofibroma: analysis of 42 cases and important aspects of endoscopic approach.

OBJECTIVE To determine the general characteristics of 42 patients who were operated for juvenile nasopharyngeal angiofibroma (JNA); and to determine the important aspects and the advantages of endoscopic transnasal approach over other techniques. METHODS Forty-two patients with JNA, 12 of whom were operated with endoscopic transnasal approach at a tertiary care center between March 1987 and February 2008 were evaluated retrospectively. The general characteristics of the patients, presenting signs and symptoms, the surgical approach performed, tumor stage, whether preoperative embolization was performed and rates of recurrence were studied. Patients who underwent surgery with endoscopic transnasal approach were compared to others who underwent surgery with different techniques. RESULTS One patient was female and the remaining 41 patients were male. Twelve patients underwent endoscopic removal of the tumor. Lateral rhinotomy was used for 10 patients, degloving approach for 7 patients, transpalatal approach for 6 patients, combined approach for another 6 patients and finally midfacial splitting for 1 patient. Seventeen percent of the patients had referred with recurrent diseases. According to staging system of Radkowski, about half of the patients belonged to stage IIA or IIC. The mean age was 16 and the most common presenting symptom was nasal obstruction. Preoperative embolization rate was 59.5% while recurrence rate in the postoperative period was 17%. In non-endoscopic approaches, the tumor contiguity and operative plan were determined via radiological data. In operations performed with endoscopic transnasal approach in patients with JNA, the radiological data as well as a detailed endoscopic tumor examination were utilized and it was observed that tumor invaded the middle turbinate in 67% and both the septum and middle turbinate in 42% of the patients. While preoperative embolization was performed only in larger tumors before 1998, it was recruited in all subjects after 1998. Preoperative and postoperative hemorrhage were less, and durations of packing and hospitalization were shorter in patients operated with endoscopic approach plus preoperative embolization. CONCLUSION Endoscopic transnasal approach has advantages of no non-cosmetic sequela, less hemorrhage and no disruption in facial skeleton. Besides, this method allows better visualization of tumor contiguity and enables dissection and ligature of vascular structures in JNA surgery. The rate of tumors associated with middle turbinate and septum is greater than that is assumed in patients with JNA. Starting the tumor excision with partial resection of the middle turbinate and subperiostal dissection of the septum and anterior sphenoidal wall, and avoiding direct contact with the tumor might decrease the amount of bleeding.

Anatomic variations of sphenopalatine artery and minimally invasive surgical cauterization procedure.

Background Sphenopalatine artery (SPA) ligation or cauterization stands to be one of the most common management options of refractory epistaxis. Ramification pattern of SPA as it passes through sphenopalatine foramen (SPF) has not been clearly established. The aim of this study is to investigate situations in which middle meatal approach may fail due to anatomic variations of SPA and to define a minimally invasive surgical cauterization procedure. Anatomic variations of SPA were determined by microdissection of 20 adult sagittally cross-sectioned head specimens. Methods Branching characteristics of SPA and its anatomic relations were evaluated and anatomic variations were noted. Results SPA was generally (80%) forming branches within SPF before entering into the nasal cavity. In 20% of the specimens, SPF was located superior to the horizontal lamella of the middle turbinate, and accessory foramen was present in 10%. In 10% of the cases, the posterior lateral nasal branch was situated as two branches in a deep sulcus in the middle meatus. Conclusion The ramification pattern of SPA can not be fully exposed without resection of the posterior part of the middle turbinate via the middle meatal approach. Two-step procedures are advocated in reducing failure rates. Previously defined two-step procedures are relatively invasive. A less invasive procedure is defined based on the variations of SPA and SPF.

Blood supply of the inferior turbinate and its clinical applications.

One of the most effective treatments of inferior turbinate (IT) hypertrophy is surgical reduction. Bleeding from the IT branch of the posterior lateral nasal artery (ITB) may interfere with the outcome of IT surgery. The aim of this study is to define the anatomic localization of the ITB and its variations and to investigate its clinical importance. Anatomic relations of the ITB were determined by microdissecting 20 adult, sagittally cross‐sectioned head specimens. Branching characteristics of the ITB and its anatomical relations were evaluated. The most consistent two markers to define the ITB on the lateral nasal wall were the posterior attachment of the IT (PAIT) and the posterior attachment of the middle turbinate (PAMT). Mean horizontal distances of the ITB from the PAIT and the PAMT were 7.2 mm ± 2.8 mm (2.5–11.8 mm) and 8.2 mm ± 2.8 mm (4–14.6 mm), respectively. ITB was the only major artery that supplied the IT in 85% of the specimens, and, in 15%, there was more than one artery. ITB was located lateral to the IT in 95% and medial to the IT in 5%. The ITB coursed on the lateral nasal wall, vertically between the middle and ITs and always anterior to the PAIT. All the variations of blood supply to the IT were within a one square centimeter area, ∼1‐cm anterior to the PAIT. Successful cauterization of this particular area may be an alternative cauterization site in IT surgery. Clin. Anat. 23:770–776, 2010.

Acute invasive fungal rhinosinusitis: Survival analysis and the prognostic indicators.

Background Acute invasive fungal rhinosinusitis (AIFR) is a highly mortal, progressive fungal infection of the paranasal sinuses and surrounding structures that is almost always seen in patients who are immunocompromised. Despite the use of newer antifungal treatments and early diagnosis, the prognosis of AIFR does not improve significantly. Due to the higher incidence of patients who are immunocompromised and have more complex disease, AIFR is a growing medical issue in tertiary medical centers. Objective The aim of this study was to present the outcomes and analyze the prognostic indicators of patients with AIFR who underwent surgery. Methods Between October 2009 and November 2014, 37 patients who underwent surgery for AIFR at a tertiary care university hospital were included in the study. Overall survival and disease-specific mortality and survival rates were calculated to estimate survival function. The impact of age, sex, underlying disease, extent of AIFR, applied medical treatment, and causative species (mucormycosis, aspergillosis) were also taken into consideration. Also, the effect of a variety of laboratory parameters, such as hemoglobin, leukocyte, neutrophil, lymphocyte, platelet, and C-reactive protein (CRP) levels, to survival were evaluated. Results The median follow-up time was 58 days (interquartile range = 304). Overall and disease-specific mortality rates were 64.9 and 51.4%, respectively. Fever was the most common symptom (86.5%), along with nasal obstruction and/or fullness (48.6%) and epistaxis (48.6%). Age and sex did not have a significant impact on survival (p > 0.05). Palate involvement was significantly associated with mortality (p < 0.05). According to the results of Cox, regression analysis for disease-specific mortality rate, leukocyte and neutrophil counts as well as CRP levels had a significant effect on survival function (p < 0.05). Conclusions Palatal involvement was associated with a higher mortality in our study. Also, leukocyte counts, neutrophile counts, and CRP values had a significant impact on survival function. The reversal of the underlying disease and immunosuppression is as important as the medical and surgical treatment.

Does Mannose-Binding Lectin Have a Role in Adult Turkish Patients with Nasal Polyposis?

Objective Mannose-binding lectin is an important component of innate immunity; it initiates the lectin pathway of complement activation critical for innate immunity. Failure of local innate defenses may result in defective responses that lead to the persistent carriage of microorganisms or ongoing inflammation. This study investigated the role of mannose-binding lectin levels and the frequency of the 6 functional mannose-binding lectin polymorphisms in Turkish individuals with nasal polyposis. Study Design A case-control study. Setting University hospital. Subjects and Methods Fifty-one patients with nasal polyposis and 53 healthy controls were enrolled. Serum mannose-binding lectin levels were obtained by enzyme-linked immunosorbent assay (ELISA) using the mannose-binding lectin oligomer ELISA kit. Mannose-binding lectin 2 genotyping was performed by isolating the genomic DNA from leukocytes. Results Mean mannose-binding lectin levels were 1693.2 and 1887.8 in the patient and control group, respectively. Although mannose-binding lectin levels were lower in the patient group, the difference was not statistically significant (P > .05). No overall association was observed between the mannose-binding lectin genotype and susceptibility to nasal polyposis (95% confidence interval = 0.716–4.389, odds ratio = 1.773). The mutant allele frequencies of the 3 structural polymorphisms did not differ significantly between the nasal polyposis patients and the controls (P = .659). Conclusions Mannose-binding lectins are not involved in the pathogenesis of nasal polyposis in adult Turkish patients, but additional research is needed for further comment.

Primary Sinonasal Malignant Melanoma: Effect of Clinical and Histopathologic Prognostic Factors on Survival.

Background: Mucosal melanoma is a rare malignancy arising from melanocytes of the mucosal surfaces. The pattern and frequency of oncogenic mutations and histopathological biomarkers have a role on distinct tumour behaviour and survival. Aims: To assess the rate of C-KIT positivity and its effect on survival of surgically treated sinonasal malignant melanoma patients with other histopathological biomarkers and clinical features. Study Design: Retrospective cross-sectional study. Methods: Seventeen sinonasal malignant melanoma patients with a mean age of 65.41 (39-86) years were included. Overall survival and disease-specific survival rates were calculated. The impact of age, gender, stage and extent of the disease, type of surgery, and adjuvant therapies were also taken into consideration. The effect of mitotic index, pigmentation, S100, HMB-45, Melan-A and C-KIT on survival were evaluated. Results: Median tumour size was 20 mm (interquartile range=27.5 mm). Pigmentation was present in 7 (41.2%) cases. Median number of mitoses per millimetre squared was 11 (interquartile range=13). Melan A was positive in 7 (41.2%) patients, ulceration was present in 6 cases (35.3%), and necrosis was present in (47.1%) 8 cases. Six patients (35.3%) were positive for S100, 14 (82.4%) specimens stained positive for HMB-45 and C-KIT (CD117) was positive in 9 cases (52.9%). Three patients (16.7%) developed distant metastasis. Five year overall and disease free survival rates were 61.4% and 43.8%, respectively. Conclusion: Although C-KIT positive sinonasal malignant melanoma patients (52.9%) can be candidates for targeted tumour therapies, the studied clinical or histopathological features along with C-KIT seem to have no significant effect on survival in a small group of patients with sinonasal malignant melanoma.

Endoscopic endonasal approach to the vidian nerve and its relation to the surrounding structures: an anatomic cadaver study

AbstractPurposeThe aim of this study was to investigate the neurovascular structures and their relevant anatomy with the endonasal endoscopic transpterygoid approach on fresh human cadavers. In addition, the relationship between the vidian nerve, ICA and surrounding structures were investigatedMethodsThis study was carried out at an otolaryngology department of a tertiary medical center between June 2014 and June 2015. Ten fresh human cadavers were included in this study. Pterygopalatine fossa was explored via an endoscopic endonasal transpterygoid approach. Same surgical dissection procedures were performed on all cadavers: maxillary antrostomy, anterior and posterior ethmoidectomy, sphenoidotomy, transpterygoid pterygopalatine fossa and vidian canal dissection.ResultsMean distance between the anterior nasal spine and ethmoidal crest was 60.35 ± 1.31 mm (range 59–64 mm). Mean distance between the sphenopalatine foramen and superior border of choana was 18.30 ± 1.38 mm (range 17–22 mm). Mean distance between the vidian canal and sphenopalatine foramen was 6.30 ± 0.47 mm (range 5.5–7 mm). Mean distance between the vidian canal and anterior nasal spine was 64.6 ± 1.71 mm (range 62–67 mm). Foramen rotundum was located superior lateral to the vidian canal in all specimens. Mean distance between foramen rotundum and vidian canal was 9.45 ± 0.60 mm (range 8.5–10.5 mm). Course of the greater palatine nerve was always medial to the descending palatine artery. The mean length of the vidian nerve from the petrous ICA to the point the nerve exits the vidian canal (vidian canal length) was 17.90 ± 1.59 mm (range 16–20 mm).ConclusionsThe distances between the vidian canal and surrounding neurovascular structures would help the skull base surgeon in this narrow and complex area.

Evaluation of Inferior Turbinate Stroma with Ultrasound Elastography in Allergic Rhinitis Patients

Background: Diagnosis of allergic rhinitis is primarily based on history, physical examination and allergy testing. A technique that noninvasively evaluates the soft tissue changes in the nasal mucosa of allergic rhinitis patients has not been defined. Aims: To assess nasal mucosal changes and measure the submucosal fibrosis in allergic rhinitis patients with sonoelastography. Study Design: Case control study. Methods: Eighty-eight turbinates of 44 patients were included in the study. There were 23 prick test positive allergic rhinitis patients. The control group constituted 21 patients. The rhinitis quality of life questionnaire and the visual analogue scale were applied to the allergic rhinitis patients. A higher visual analogue scale score indicated more severe allergic rhinitis symptoms. Sonoelastographic measurements were made from the lateral nasal wall. The propagation speed of sound waves was recorded in m/s. The presence of asthma and the type of allergic rhinitis (seasonal or perennial) was noted. Results: Ten patients had seasonal allergic rhinitis and thirteen patients had perennial allergic rhinitis. Six patients (26.1%) had accompanying asthma along with allergic rhinitis. The median visual analogue scale score was 7 (3-9) in allergic rhinitis patients. The median symptom duration was 7 (1-24) months. The median quality of life questionnaire score was 3.39 (1.68-5.43) points. The median sonoelastography scores of allergic rhinitis patients and healthy subjects were 2.38 m/s (0.9-4.47) and 2.42 m/s (1.62-3.50), respectively. Sonoelastographic measurements of seasonal and perennial allergic rhinitis patients did not differ significantly (p>0.05). The presence of asthma did not have a significant impact on the elastography measurements (p>0.05). However, regression analysis revealed a significant inverse correlation (coefficients: B=0.005, standard error=0.097, beta 0=0.008) between the visual analogue scale and sonoelastography scores (p<0.05). Conclusion: Sonoelastography was not suitable as a diagnostic tool in allergic rhinitis. Reduced sonoelastography scores were measured in more symptomatic patients. Higher visual analogue scale scores could be an indicator of disease severity.