Jaromír Astl

The Role of NBI HDTV Magnifying Endoscopy in the Prehistologic Diagnosis of Laryngeal Papillomatosis and Spinocellular Cancer

Narrow band imaging (NBI) HDTV (high definition television) magnifying endoscopy is considered to be superior for the accurate display of the microvascular patterns of superficial mucosal lesions. Observation of changes in intraepithelial papillary capillary loops (IPCL) can help distinguish benign from malignant lesions as part of an “optical biopsy.” However, IPCL changes in papillomas may be mistaken for spinocellular cancer (SCC). The aim of the study was to determine whether observing microvascular changes alone is sufficient for discriminating between laryngeal SCC and papillomatosis. An additional aim was to identify associated characteristics that could clarify the diagnosis. The study included 109 patients with a suspected laryngeal tumor or papilloma. HDTV NBI magnifying endoscopy was performed during direct laryngoscopy. It was possible to visualize IPCL changes in 82 out of 109 patients (75.2%). In 71 (86.6%) patients, the diagnosis was correctly determined. In 4 (4.9%) cases, the diagnosis of SCC was expressed on the basis of finding pathologic IPCL, but histology did not demonstrate malignancy. To achieve a correct diagnosis using HDTV NBI magnifying endoscopy, it is important not only to observe changes in the shape of IPCL but also to note possible papillary structures with central-axis capillaries typical of papillomatosis.

Coincidence of thyroid tumor and thyroglossal duct remnants. Review of the literature and presentation of three cases

Aims and Background The coincidence of benign or malignant thyroid tumors with thyroglossal duct remnant (TDR) cysts is rare. Although the precise etiology is still unclear, thyroid origin and spread from a primary site have been suggested and this obviously has important implications for the therapeutic approach. Three cases of thyroglossal duct carcinoma are presented and its management is discussed on the basis of the current rationale for treatment of thyroid cancer. The indication for surgery depends on positive findings in the thyroid gland (nodules, FNAB). The aim of this study was to review our experience in the management of papillary thyroid diseases associated with TDR. Materials and Methods The records of three patients with thyroid tumors associated with TDR treated at the Department of ENT and Head and Neck Surgery of the First Medical Faculty UK of Prague between January 1991 and January 2001 were analyzed. We searched for risk factors of thyroid carcinoma: history of ionizing radiation, history of thyroid diseases, age, tumor size, tumor spread and histopathological factors. Results We used a triple approach consisting of clinical and ultrasound examination and fine-needle aspiration biopsy for preoperative assessment. Our diagnostic and therapeutic procedures included TDR excision (Sistrunk or Schlange procedure) and total thyroidectomy. Although the therapeutic approach could be a matter of discussion, most patients agreed with our suggestion of relatively radical but non-mutilating treatment. Postoperative radiation or radioiodine ablation is considered in cases of TDR carcinoma or thyroid carcinoma associated with TDR. Oncological follow-up included clinical and ultrasound examination three times during the first year, twice in the second year, and once yearly thereafter. Tumor marker evaluation and/or scintigraphy were performed 6, 12 and/or 24 months following surgery.

Pilot study: Association between Helicobacter pylori in adenoid hyperplasia and reflux episodes detected by multiple intraluminal impedance in children

OBJECTIVES The aim of this pilot study was to investigate an association between laryngopharyngeal reflux detected by combined multiple intraluminal impedance and pH monitoring and Helicobacter pylori in adenoid hyperplasia detected with real time polymerase chain reaction (PCR). METHODS The study group consisted of 30 children (median age 5.34 years) with extraesophageal symptoms of gastroesophageal reflux disease with adenoid hyperplasia. All children underwent adenoidectomy with subsequent PCR detection of H. pylori DNA in the tissue and multiple intraluminal impedance and pH monitoring. The most proximal impedance sensor was located 1cm caudal to the entrance of the oesophagus. RESULTS We found significant differences in the number of reflux episodes among patients with PCR positivity (median 35) and negativity (median 0) of H. pylori (p-value of Mann-Whitney U-test 0.0056). Patients with PCR positivity of H. pylori had significantly more reflux episodes reaching the upper oesophageal sphincter (p-value of Mann-Whitney U-test 0.023). The absence of reflux episode was the only independent factor for PCR negativity of H. pylori in the multiple logistic regression model. CONCLUSIONS These results support the hypothesis that reflux episodes reaching the upper oesophageal sphincter may play an important role in the transmission of H. pylori into lymphoid tissue of the nasopharynx and thus may contribute to adenoid hyperplasia in children.

Helicobacter pylori Isolated from Patients with Tonsillar Cancer or Tonsillitis Chronica Could Be of Different Genotype Compared to Isolates from Gastrointestinal Tract

Helicobacter pylori from patients with different diseases, including so-called autoimmune thyroiditis, chronic tonsillitis and tonsillar cancer, was isolated and cultured. It was identified according to the genotype using labeled hybridization probes complementary to six sequences ofcagA andvacA genes. Different types of strains were found in isolates from gastrointestinal tract and patients suffering from thyroiditis. Six out of seven genotyped isolates from patients in ourDepartment of Otorhinolaryngology and Head and Neck Surgery exhibited the same genotype, differing from isolates obtained from other patients; the 7th isolate originated from a patient who had undergone surgery for deviatio septi nasi, at the same time suffering from autoimmune thyroiditis, having confirmed gastric infection byH. pylori from biopsy. This data made it possible to formulate the hypothesis on probable association of specificH. pylori genotype with chronic tonsillitis and tonsillar cancer. We assessed commercial transport media and improved nucleic acid isolation techniques and the RT-PCR-based tests, which allowed us to skip a culture step and to test directly the patients’ samples; however, for ful confirmation of our hypothesis and explanation of possible mechanisms of the contribution ofHelicobacter sp. to the pathogenesis of the disease further data are to be collected and evaluated.

Thyroid carcinoma surgery in children and adolescents – 15 years experience surgery of pediatric thyroid carcinoma

OBJECTIVES The purpose of this study is to evaluate the characteristics of thyroid gland surgery focusing on malignancies at the pediatric age with the main concern on treatment results and complications in extensive primary treatment. METHODS The records of all patients 18 years and younger with surgically treated thyroid diseases in the Prague Hospital, Motol, between 1991 and 2006 were retrospectively reviewed. RESULTS Thyroid surgery was performed on 148 pediatric patients (including 56 carcinomas). The youngest patient involved in the study was seven years old, the oldest patient 18 years old (mean 13.7 years). Most frequent histological cancer type was PTC (42 cases, 75%). Follicular cancer was diagnosed in five cases (8.9%) and medullar cancer in nine cases (16.1%). A prophylactic thyroidectomy was performed in three cases (5.4%) without clinical signs of thyroid tumor with diagnosed RET gene mutation. CONCLUSIONS We consider total thyroidectomy with subsequent radioiodine ablation and TSH suppression as the basic approach in the treatment protocol of pediatric WDTC. The observed 100% recurrence-free and overall survival together with a low incidence of postoperative complications strongly supports the idea of a total thyroidectomy with selective neck dissection in the treatment of metastases of WDTC and MTC.

Prevalence of Helicobacter pylori in adenotonsillar hypertrophy in children

Abstract Conclusion: Our results encourage the notion that the pharynx could be an extragastric reservoir of Helicobacter pylori (HP). The study confirmed the presence of HP in adenotonsillar tissue in children. It could have importance in the pathophysiology of upper respiratory diseases. However, its precise role in these processes remains unclear and requires further studies. Objective: A prospective study was carried out to evaluate the presence of HP in tonsillar and adenoid tissue in children. The study focused on real-time PCR analyzing CagA and VacA genotypes of HP strains. Methods: A total of 37 consecutive pediatric patients with adenotonsillar hypertrophy indicated for surgery were observed in a prospective study. Adenoidectomy and/or tonsillectomy was performed in each patient; 49 specimens were taken, 32 from adenoids and 17 from tonsils. The presence of HP and its genotype were tested in all samples by real-time PCR analysis. Results: Of 49 samples analyzed, 48 were positive for the presence of HP (98%), so only 1 sample was negative. While the genotype VacAs1bm2 was definitely dominant in adenoid tissue, wider distribution was observed in tonsillar tissue. Cag+ strains represented one-fifth of all samples (21%).

Surgical treatment strategy for thyroid gland carcinoma nodal metastases

The authors present their experience with surgical treatment for nodal metastases of thyroid carcinoma based on neck dissections. The specificity of the surgical approach to the lymph nodes was determined by the biologic behavior of each thyroid tumor. Using the available literature on metastases from thyroid tumors, an opinion is supported that surgery for differentiated carcinomas (papillary and follicular neoplasms) can be more conservative and can be safely limited to modified neck dissections. In contrast, a more extended type of selective neck dissection, and only rarely a comprehensive neck dissection, is needed for medullary carcinoma. Because of its rapid spread to distant sites local aggressivity, extirpation of individual lymph nodes or neck dissection is not justified in patients with anaplastic thyroid carcinoma.

Ultrasonography (B scan) in the head and neck region

Abstract Background: Ultrasonography has a unique and valuable role in imaging the neck region. It helps the clinician provide excellent and reproducible anatomic images that are safe, comfortable for the patients and moderate in cost. The role of ultrasonography has evolved to provide important data in many clinical indications: to determine of pathology, volumetry, vascular status, the size of tumour, guided fine needle biopsy. A new approach uses the small ultrasound transducer for intraoperative navigation. Ultrasonography plays an important role in the precise staging as a basic requirement for an effective concept of tumour therapy and follow-up. Developing of protocols for use of ultrasonography has begun to examine the wide spread applicability to answer some key questions concerning the technology, including the clinical relevance of upstaging that occurs with a more detailed examination of the neck tumours and neck lymph node metastases. Methods: Patients (2085) were examined with B-mode sonography. Ultrasonography was performed with Hitachi EUB 420 7.5 MHz transducer. The aim of the present study was to describe the influence of different types of ultrasound imaging of the neck pathology. Results: The thyroid gland was examined in 513 cases, lymph nodes in 476 cases, supraglottic tumours in 53 cases, parotid gland in 304 cases, submandibular salivary gland in 61 cases, neck cyst 41 cases, laryngopharyngeal and oropharyngeal tumour in 241 cases, neck in follow-up in 321 cases (positive in 46 cases) and other pathologies in 75 cases (laryngocele, abscesses and others). The specificity of ultrasonography depends from operator, type of imaging, size and type of pathology; for thyroid gland, parotid gland and submandibular salivary gland, it is over 90%, in other pathologies, only 50–87%. Conclusions: Ultrasonography (B scan) in the head and neck region is a technically demanding procedure. We recommend ultrasonography in the standard management of head and neck diseases. Intraoperative ultrasonography is a new approach to lymph nodes metastases and/or thyroid, parathyroid diseases. The other imaging methods (CT, NMR, PET-scan) we recommended facultative only. We use the ultrasonography as a cost effective, precious, no-radiation imaging method.

Minimally Invasive Video-Assisted versus Minimally Invasive Nonendoscopic Thyroidectomy

Minimally invasive video-assisted thyroidectomy (MIVAT) and minimally invasive nonendoscopic thyroidectomy (MINET) represent well accepted and reproducible techniques developed with the main goal to improve cosmetic outcome, accelerate healing, and increase patients comfort following thyroid surgery. Between 2007 and 2011, a prospective nonrandomized study of patients undergoing minimally invasive thyroid surgery was performed to compare advantages and disadvantages of the two different techniques. There were no significant differences in the length of incision to perform surgical procedures. Mean duration of hemithyroidectomy was comparable in both groups, but it was more time consuming to perform total thyroidectomy by MIVAT. There were more patients undergoing MIVAT procedures without active drainage in the postoperative course and we also could see a trend for less pain in the same group. This was paralleled by statistically significant decreased administration of both opiates and nonopiate analgesics. We encountered two cases of recurrent laryngeal nerve palsies in the MIVAT group only. MIVAT and MINET represent safe and feasible alternative to conventional thyroid surgery in selected cases and this prospective study has shown minimal differences between these two techniques.

Helicobacter pylori – Not Only a Gastric Pathogene?

Petr Lukes1, Jaromir Astl1, Emil Pavlik2, Bela Potuznikova2, Jan Plzak1,3, Martin Chovanec1,3 and Jan Betka1 1Charles University in Prague, 1st Faculty of Medicine, Department of Otorhinolaryngology and Head and Neck Surgery, Faculty Hospital Motol, Prague 2Charles University in Prague, 1st Faculty of Medicine, Institute of Immunology and Microbiology, Prague 3Charles University in Prague, 1st Faculty of Medicine, Institute of Anatomy, Prague Czech Republic