Semih Oncel

Evaluation of prognostic factors and middle ear risk index in tympanoplasty

OBJECTIVE: The aim of this study was to examine the role of the prognostic factors and middle ear risk index on the success of tympanoplasty. STUDY DESIGN: Case series. SUBJECTS AND METHODS: The charts of 231 patients who underwent tympanoplasty operations between 2002 and 2007 were reviewed. Prognostic factors such as age, sex, presence of systemic diseases, location and size of perforation, duration of dry period, presence of myringosclerosis, presence of septal and conchal pathology, operation type, and status of the opposite ear and middle ear risk index were investigated. RESULTS: The overall success rate was 74.4%. Multivariate analysis was carried out on significant prognostic factors to obtain independent variables and yielded the following results (95% CI): size of the perforation (<50%) (OR:8.11), healthy opposite ear (OR:5.64), more than 3 months dry period (OR:2.21), absence of myringosclerosis (OR:4.01) and low middle ear risk index (OR:87.1). CONCLUSION: Size of the perforation(<50%), healthy opposite ear, absence of myringosclerosis, more than 3 months dry period, and low middle ear risk index were found to be significant independent prognostic factors.

Pharyngocutaneous Fistula after Total Laryngectomy: Less Common with Mechanical Stapler Closure

Objectives: The aim of the study was to compare the incidences of pharyngocutaneous fistula after total laryngectomy between patients who underwent manual and mechanical suturing for pharyngoesophageal closure. Methods: In a retrospective and prospective nonrandomized clinical study conducted at a single tertiary medical center between May 2002 and April 2009, we compared the incidence of pharyngocutaneous salivary fistula between two groups of patients after total laryngectomy. Sixty-one consecutive patients who underwent mechanical suturing with a 60-mm linear stapler (group A) were prospectively enrolled, and 121 patients who had undergone manual suturing (group B) were retrospectively reviewed. Results: The groups were similar in terms of age, gender, comorbidities, TNM (tumor, node, metastasis) stage, and laryngeal tumor extension. The incidence of pharyngocutaneous salivary fistula was 4.9% in group A and 19.8% in group B (p = 0.014). Conclusions: Mechanical stapler closure of the pharynx after total laryngectomy was associated with a significant reduction in the incidence of pharyngocutaneous fistula compared with manual suture in selected cases.

Supracricoid Partial Laryngectomy Analyses of Oncologic and Functional Outcomes

Objective The aim of this study was to analyze the functional and oncologic results of supracricoid partial laryngectomy. Study Design Case series with chart review. Setting Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey. Subject and Methods The medical records of 56 patients, who underwent supracricoid partial laryngectomy between March 2002 and December 2010, were reviewed in this study. Forty-three patients underwent supracricoid partial laryngectomy with cricohyoidopexy, and 13 patients underwent cricohyoidoepiglottopexy. The overall and disease-specific survival, local control rates, and the mean time of decannulation and nasogastric tube removal were evaluated. Association of type of surgery with the functional and oncologic outcomes was evaluated and statistically compared. Results The median follow-up period was 58 months. The 1-, 3-, and 5-year overall survival rates were 100%, 96.4%, and 82.1%, respectively. The 1-, 3-, and 5-year local control rates were 100%, 96.1%, and 92.5%, respectively. Type of surgery did not show any significant difference in survival and local control rates (P = .546, P = .455). The mean (SD) decannulation and nasogastric feeding tube removal time was 11.43 (2.03) and 16.79 (3.51) days, respectively. The mean time of decannulation and nasogastric tube removal was significantly longer in patients who underwent cricohyoidopexy when compared with those who underwent cricohyoidoepiglottopexy (P = .002, P = .000). Conclusion Although delaying deglutition functions could be termed a disadvantage of supracricoid laryngectomy, especially with cricohyoidopexy, supracricoid laryngectomy has reliable oncologic and functional results for locally advanced laryngeal cancers while maintaining laryngeal functions.

Evaluation of P53, P63, P21, P27, Ki-67 in Paranasal Sinus Squamous Cell Carcinoma and Inverted Papilloma

Using a molecular genetic approach, we try to confirm the molecular alterations of inverted papilloma and clarify its status as a putative precursor lesion of sinonasal squamous cell carcinoma. To better understand its genetics, we investigated the immunohistochemical protein expression patterns of cell-cycle-regulators p53, p63, p21, p27 and proliferation marker Ki-67 in 22 inverted papilloma and 9 squamous cell carcinoma of the sinonasal tract. Significantly elevated levels of p53 and p63 in squamous cell carcinoma of sinonasal tract compared with inverted papilloma were revealed. Ki-67-stained neoplastic cell nuclei were found in a significantly higher percentage of squamous cell carcinoma of sinonasal tract than in inverted papilloma, whereas no variation of p21 and p27 expression was identified. This work first examined the immunohistochemical overexpression of p63 in sinonasal inverted papilloma and squamous cell carcinoma. In conclusion, this is a first study shedding light on the expression of p63 in tumors of paranasal sinuses.

Schwannoma (neurilemmoma) of the facial nerve presenting as a parotid mass

A 32-year-old male presented with a mass in the parotid gland. Superficial parotidectomy was performed. Histopathologically the tumour was found to be schwannoma (neurilemmoma) and because this is unusual, the case is presented together with the histopathological findings.

Autoclaving the ossicles provides safe autografts in cholesteatoma

OBJECTIVE The choice of the graft in ossicular chain reconstruction during middle ear surgery for cholesteatoma is a subject still discussed on. In order to clarify the discussion of reuse of the autologous ossicles obtained during middle ear surgery for cholesteatoma, we evaluated the probability of residual disease histologically and the safety of the ossicles after autoclavization, the most promoting alternative method to eradicate residual cholesteatoma and infection on them. METHODS The specimens used in this study were eroded twenty-seven ossicles (22 incuses, 5 malleoli) which were removed from the 27 consecutive patients operated because of cholesteatomatous middle ear disease. They were grouped as follows: Group 1, Fifteen ossicles examined histopathologically directly. Group 2, Five ossicles autoclaved for 20 min at 134 degrees C and then examined histopathologically. Group 3, Five ossicles autoclaved for 20 min at 134 degrees C after mechanical surface cleaning by a fine diamond drill, examined histopathologically. Group 4, Two ossicles removed from two different patients were placed in their mastoid cavities in order to be examined after access in the second-look operation. While one ossicle was only autoclaved, the other was mechanically cleaned by a drill before autoclavization (for 20 min at 134 degrees C). The ossicles were examined histopathologically after the removal at the second stage operation performed 12 months later. RESULTS In Group 1, all ossicles showed evidence of periosteal thickening. Additional findings were surface cholesteatoma or epithelia in 13 ossicles, surface inflammation in 12 ossicles, granulation tissue in 10 ossicles, osteitis in six ossicles. In Group 2, all five ossicles had preserved their lamellar structure but, no vital cells were seen. The lacunes that had the osteocytes was almost completely empty. The inflammatory cells were eliminated from the ossicles. In Group 3, ossicles were found well preserved with their lamellar structures and contours, with empty lacunes and eliminated inflammatory cells. In Group 4, in two ossicles of this group the lacunes were replaced by the new migrated viable osteocytes with evidence of new bone formation and neovascularisation. No new inflammatory focus or epithelia were found on the surfaces of the ossicles. The shape and the contour of the ossicles remained unchanged. CONCLUSION In cholesteatoma surgery, ossicles with minimal erosion and adequate thickness can be used after autoclavization. In this study, it was observed histopathologically that the autoclaving autologous ossicles before ossiculoplasty in cholesteatomatous middle ear is a safe and reliable method.

Leiomyosarcoma of the parotid gland

A 36-year-old patient with a primary leiomyosarcoma of the left parotid gland is presented. To our knowledge this is only the second case of a parotid leiomyosarcoma in the world according to the literature review.

Complications of tracheoesophageal puncture and speech valves: retrospective analysis of 47 patients.

OBJECTIVES This study aims to evaluate the complications of tracheoesophageal puncture (TEP) for voice restoration and speech valves in patients undergoing total laryngectomy. PATIENTS AND METHODS Between January 2006 and June 2011, 47 male patients (mean age 62.8±1.2 years; range 41 to 80 years) who underwent TEP and speech valve for voice restoration after total laryngectomy were retrospectively analyzed. Secondary TEP was performed and Provox indwelling voice prosthesis were inserted in all patients. Demographic, disease and treatment characteristics of patients were recorded. Complications related to TEP and speech valves, the management of complications and clinical conditions of complete closure of TEP were also recorded. RESULTS Tracheoesophageal puncture and speech valve related complications were observed in 20 patients. The majority of complications were minor complications including granulation tissue formation (n=2, 4.2%), deglutition of prosthesis (n=6, 12.7%) and TEP enlargement/leakage around prosthesis (n=9, 19.1%). Major complications were observed in three patients. Two of them were life-threatening complications; a mediastinitis (n=1, 3.1%) and paraesophageal abscess (n=1, 3.1%), and both appeared in the first month of the postoperative period. The overall complication rate was 42.6% during mean follow-up of 15.3 months. Tracheoesophageal fistula enlargement (n=9, 19.1%) was the most common minor complication and the most common cause of complete closure of TEP in this study. CONCLUSION Tracheoesophageal puncture for voice restoration is not an entirely innocent procedure without any complications. Patients should be monitored for TEP-related complications in the early and late postoperative period.

Giant external carotid artery pseudoaneurysm presenting as a parotid mass

A 17-year-old girl with fever and malaise had received an unknown antibiotic therapy for 10 days elsewhere. Because her symptoms had increased, she received 2 more different unknown antibiotic treatments with the diagnosis of sepsis. Her medical status deteriorated, and she was referred to another hospital with the diagnosis of pneumonia and adult respiratory distress syndrome. Laboratory findings were as follows: erythrocyte sedimentation rate (ESR), 35 mm/hour; white blood cell count (WBC), 31,000/mm3; and high WBC in the urine. Hemoculture and tests for tuberculosis (PPD and chest x-ray film) were negative. She was treated with nonspecific antibiotherapy, mechanic ventilation, and blood transfusion, and she was discharged after 20 days of hospitalization. On the day she was discharged, she had right otalgia, hoarseness, and a 2-cm mass below the lobule; she received another antibiotic for 10 days. After this treatment her symptoms increased gradually, and she had headache and dysphagia. The patient was admitted to our clinic and hospitalized for further investigation and treatment. Examination of her neck revealed a tender, pulsatile, smooth-surfaced, and hyperemic mass occupying the parotid, submandibular, and carotid regions extending to the greater cornu of the hyoid bone inferiorly with a dimension of 8 × 8 cm. Examination of the oropharynx revealed that her right tonsil and lateral pharyngeal wall were displaced medially. Indirect laryngoscopy showed restricted mobility of the arytenoid. The mandibular branches of the right facial nerve and glossopharyngeal and hypoglossal nerves were paralyzed. Other clinical and laboratory findings were normal. Chest x-ray film, ultrasonography (USG) of the abdomen, and CT of the thorax were normal. There was an aneurysmal formation with a severe turbulent flow showing the pattern of the thrombotic component of the aneurysm during Doppler USG of the mass. The CT scan of the neck showed a lobulated, contoured aneurysmal mass of the right external carotid artery suggesting a pseudoaneurysm (Fig 1). Dense contrast filling with thrombotic parts in it were detected. The aneurysmal mass displaced the parotid gland laterally and the mandibular ramus anterolaterally and extended to the parapharyngeal space and the infratemporal fossa. The MRI of the neck revealed an aneurysmal mass of the right external carotid artery with a heterogeneous structure indicating a turbulent flow and hyperintense region belonging to the thrombotic component at the periphery of the aneurysm (in T1and T2weighted scans). Selective angiography of the right common carotid artery revealed an irregular contoured pseudoaneurysm of the external carotid artery distal to the superior thyroid artery with a diameter of 7 cm. In the cerebral CT scan there was an abscess formation with a dimension of 2 cm medial to the left posterior parietal space (water-shed infarct region) and a focal area of cerebritis at the periphery of the abscess. In the operation a Montgomery incision with an extension to the mentum was used. An aneurysmal sac was found to begin just from the upper limit of the superior thyroid artery and to fill the carotid, submandibular parotid region and the parapharyngeal space. The sac was full of thrombus, was adherent to the surrounding structures, and had an irregular border. The right hypoglossal, buccal, and cervicomandibular branches of the facial nerve were surrounded by the pseudoaneurysm. The external carotid artery was ligated just distal to the bifurcation. A total parotidectomy was performed, and the buccal and cervicomandibular branches of the facial nerve and the distal portion of the hypoglossal nerve were dissected free from the mass. The pseudoaneurysm was also seen to fill the parapharyngeal space. It was freed from the surrounding structures and totally removed. Postoperative histopathologic examination was reported to be a pseudoaneurysm with thrombus. No microorganisms could be found in the bacteriologic examination (aerobe and anaerobe cultures). Postoperative follow-up was uneventful, and the patient was discharged on the 10th day. The ischemic area in the left Giant external carotid artery pseudoaneurysm presenting as a parotid mass

Comparison of Submucosal Resection and Radiofrequency Turbinate Volume Reduction for Inferior Turbinate Hypertrophy: Evaluation by Magnetic Resonance Imaging

Abstract Inferior turbinate hypertrophy is a frequent cause of nasal airway obstruction and drastically impairs patients’ quality of life. Surgical reduction of the inferior turbinates can be used for patients who did not respond to medical therapy. A number of studies have been performed to identify the most effective technique. The aim of this study was to compare the effectiveness of submucosal resection (SMR) and radiofrequency turbinate volume reduction (RFTVR) in patients with inferior turbinate hypertrophy. A prospective, randomized case–control study was conducted. Sixty patients with inferior turbinate hypertrophy refractory to medical therapy were prospectively and randomly assigned to two groups: SMR and RFTVR. A visual analog scale (VAS) and the nasal inspiratory peak flow (NPIF) were analyzed pre- and postoperatively at the first week and second month. Magnetic resonance imaging was performed pre- and postoperatively at the second month. The surgical outcomes were compared statistically using subjective and objective measures. Significant turbinate volume reduction was achieved in both the SMR and RFTVR groups. However, turbinate volume reduction was significantly greater in the SMR than in the RFTVR group at the second month postoperatively. NIPF and VAS scores were improved after both procedures at the second month postoperatively. Beside this, surgical outcomes were significantly better after SMR in terms of NIPF and VAS scores. In this study, we demonstrated that both SMR and RFTVR are effective for inferior turbinate hypertrophy. Turbinate volume reduction, improvement of subjective nasal obstruction symptoms, and NIPF after SMR were significantly superior to those after RFTVR.