Eitan Yaniv

Laryngeal and hypopharyngeal obstruction in sleep disordered breathing patients, evaluated by sleep endoscopy

The objectives of our study were to demonstrate the patterns and sites of the upper airway (UA) collapse in obstructive sleep apnea/hypopnea syndrome (OSAHS) patients, utilizing the sleep endoscopy technique, and to describe the technique and summarize our experience in a large series of patients. UA findings during sleep endoscopy with midazolam were examined prospectively in 55 surgical candidates with OSAHS. The uvulopalantine was the most common site of obstruction (89%), followed by the tongue base, hypopharynx and larynx (33% each), and nose (21%); 72% of the patients had multiple obstructions. There was a significant correlation between the number of obstructions and the respiratory distress index (RDI). Laryngeal obstruction was typically supraglottic. Hypopharyngeal obstruction involved concentric UA narrowing. Our findings emphasize the considerable rate of laryngeal and hypopharyngeal obstructions in patients with OSAHS and suggest that their misdiagnosis may explain at least part of the high surgical failure rate of UPPP for OSAHS patients. The number of obstruction sites correlates with respiratory distress index. Sleep endoscopy is safe and simple to perform.

Antiestrogen therapy for hereditary hemorrhagic telangiectasia: A double-blind placebo-controlled clinical trial

Hereditary hemorrhagic telangiectasia (HHT) is associated with recurrent epistaxis in 90% of cases. Good response to hormone treatment has been documented, although its use remains controversial. The aim of this study was to examine the efficacy of an antiestrogenic agent, Tamoxifen, in the treatment of HHT‐associated epistaxis.

Hemostatic effect of tranexamic acid in elective nasal surgery.

Background Bleeding is the most frequent complication of nasal surgery. The aim of this prospective study was to evaluate the effectiveness of tranexamic acid (TA), an antifibrinolytic agent, in reducing bleeding during and after nasal surgery. Methods The study sample included 400 patients aged 18–60 years who underwent combination functional endoscopic sinus surgery with septoplasty and conchotomy. Two hundred patients were not given a hemostatic agent (control group) and 200 patients were administered 1 g of oral TA three times daily starting 2 hours before surgery, for 5 days. Bleeding was monitored during surgery and for 2 weeks postoperatively. Results Patients given oral TA showed significantly less operative and postoperative bleeding compared with controls. No patients required additional packing, compared with five patients in the control group. Adverse reactions to TA were minimal, and they disappeared when the treatment stopped. Conclusion TA is a safe and effective drug for the reduction of bleeding in nasal surgery. It may be recommended for routine use.

Expression of p53, Ki-67 and Bcl-2 in Parathyroid Adenoma and Residual Normal Tissue

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

The spectrum of laryngeal neoplasia: the pathologist's view.

Several types of neoplastic change with different prognostic implications typically involve the laryngeal squamous epithelium. The purpose of this review is to examine the spectrum of these changes, as well as their relationship to benign squamous epithelial proliferative states. Since these pathological changes are apt to occur in regions where the epithelial lining is typically squamous, it is important to recognize that the epithelium of the larynx varies from stratified squamous to respiratory-type, depending on the location. The lingual (anterior) surface of the epiglottis is lined by a stratified squamous type, while the laryngeal (posterior) surface is stratified squamous merging into respiratory-type. In the larynx, the supraglottic and infraglottic portions are a respiratory-type, which contrasts with the stratified squamous epithelium of the glottis. This typical distribution does show some degree of variability in those patches of squamous epithelium and is frequently seen within the respiratory-type epithelial regions. The junction between the two epithelial types may be abrupt or separated by a transitional zone.

Human topoisomerase II‐α is highly expressed in sinonasal‐inverted papilloma, but not in inflammatory polyp

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

Clinicopathologic Study and Classification of Vocal Cord Cysts

Cysts of the true vocal cords are less common than other laryngeal cysts. They are usually easily recognized and managed. Patients present with complaints of hoarseness and/or dyspnea. We report our experience with 41 cases of cysts located in the true vocal cords. Clinical and histological aspects are reviewed and discussed. A new histological classification is proposed: A: cysts lined by columnar epithelium with mucous content; B: lined by columnar epithelium with cilia; C: lined b squamous epithelium without keratinization; D: lined by squamous epithelium with keratinization.

Effect of intranasal steroids on glucose and hemoglobin A1c levels in diabetic patients.

Background Intranasal steroids are widely used for the treatment of inflammatory diseases of the nose and sinuses such as rhinosinusitis, allergic rhinitis, and nonallergic rhinitis. Along with the general otherwise healthy population, many diabetic patients use intranasal steroids as well. This study was designed to evaluate the adverse effects of long-term treatment with intranasal corticosteroid preparations in diabetic patients. Methods The study group included all diabetic patients treated with intranasal steroids for at least 3 months at primary care clinics in Clalit Health Services Central District in Israel in 2002–2007. The central database had been reviewed for demographic data, medical history, medications, and laboratory test results. Results A total of 1768 diabetic patients were treated with topical nasal steroid sprays during the study period. Data on hemoglobin A1c (HbA1c) levels both before and during steroid treatment was available for 245 patients, and data on fasting serum glucose levels at both time points was available for 163 patients. On statistical analysis, there was no change in either measure from baseline to 3 months after starting treatment (p = 0.104 and p = 0.101, respectively). Treatment with triamcinolone acetonide was associated with a significantly greater increase in fasting serum glucose levels than other preparations (p = 0.006). Conclusion Intranasal corticosteroids seem to have no adverse effects on HbA1c and serum glucose levels in diabetic patients. Their long-term use appears to be safe, provided that the patients are carefully monitored, especially those receiving triamcinolone acetonide.

Supraglottic carcinoma: a retrospective study of 114 patients

We retrospectively evaluated the management of supraglottic carcinoma at our centre during the last 35 years to determine the preferred mode of treatment. A review of the medical records yielded 114 patients with supraglottic T1 and T2 carcinoma who were diagnosed and treated in the Departments of Otolaryngology, Head and Neck Surgery, and Oncology between 1959 and 1993. Of these, 47 (41.2%) had T1 carcinoma (stage I) and 67 (58.8%) T2 (stage II). Treatment varied among radiotherapy, surgery, or combined radiotherapy and surgery. Twelve patients underwent elective neck dissection, one of whom (8.3%) was found to have occult metastases. Local failures were noted in 22 patients (11 T1: 11 T2), three of whom also had neck metastases. All except one T2 patient received radiotherapy. Radiotherapy yielded the best survival rates for T1 disease as combined therapy did for T2. Five-year recurrence rates for T1 patients were 35% for those treated by radiotherapy and 42% for those treated with combined therapy; corresponding figures for T2 patients were 39% and 28%. We suggest that patients with T1 supraglottic carcinoma be managed with radiotherapy and patients with T2 with combined therapy. We believe there is no need for elective neck dissection, especially in T1.

A New Rapid Technique for the Fixation of Thyroid Gland Surgical Specimens

One of the main diagnostic problems in thyroid pathology is to distinguish between follicular adenoma and follicular carcinoma. Thorough sampling of the nodule’s capsule is recommended in order to identify capsular invasion. However, during the hardening of the tissue, by the usual fixatives the capsule shrinks and rolls downwards and sometimes the capsule separates from the remaining tissue. The present work evaluates the use of “Lymph Node Revealing Solution” (LNRS) for the rapid fixation of different thyroid lesions as compared to that of formalin. Fifty-one unselected consecutive cases of thyroid nodules, which included various benign and malignant lesions, were examined. Each specimen was cut in two equal parts; one was fixed in LNRS, the other in formalin. Fixation in LNRS for 2 hours gave adequate results in sectioning and staining of the tissue, and excellent immunostains. Its advantage over formalin is the conservation of the natural relationship between the capsule and the rest of the tissue, on the same plane, as well as the short time required for the final diagnosis.