Snezana Jesic

Parapharyngeal space tumors: 61 case reviews.

Parapharyngeal tumors account for 0.5% of head and neck tumors. They are difficult to diagnose because they have few symptoms and are surgically inaccessible. This retrospective study included 61 patients with parapharyngeal space tumors, treated in the last 20 years. The data, obtained from the medical records, included symptoms and clinical signs, diagnostic procedures, surgical approach, postoperative complications and histopathological findings. The most common symptoms were dysphagia, foreign body sensation, pain, and symptom-free patients. For precise tumor localization and its relation to adjacent structures, computerized tomography, magnetic resonance imaging and contrast angiography were used. All the patients were treated surgically. The commonest surgical approach was transcervical, followed by transoral and combined transcervical-transoral. Histopathological examination verified that the origin of these tumors was most frequently salivary or neurogenic.

Voice Quality After Treatment of Early Glottic Carcinoma

OBJECTIVES Increasing incidence of laryngeal carcinoma and advancement in diagnostics and therapy methods, have led to constant exploration in that field. Early glottic carcinoma can be treated successfully with several procedures: cordectomy through laryngofissure, laser cordectomy, and radiotherapy. Our objective was to assess the voice quality after these different modalities of treatment. STUDY DESIGN Prospective controlled study with 69 patients, treated in a 1-year period for glottic Tis and T1a carcinoma at the tertiary medical centre. METHODS Nineteen of our patients were treated endoscopically with CO(2) laser (types III-IV cordectomy according to recommended European Laryngological Society classification of endoscopic cordectomies). Thirty-five patients underwent cordectomy through laryngofissure, 15 patients had radiotherapy. Multidimensional computer analysis of voice and speech was conducted 1, 6, and 12 months after the treatment. Three programs included 14 parameters, which were observed. RESULTS While comparing the parameters between the groups, there were significant differences in the values of fundamental frequency (Hz), jitter (%), normalized noise energy (dB), standard deviation of fundamental frequency (Hz), percent silent time (%), and sound-pressure level in the different follow-up periods (P<0.05). CONCLUSION In the long run, patients treated with radiotherapy show better voice quality in comparison with other two groups.

Temporalis Fascia Graft Perforation and Retraction After Tympanoplasty for Chronic Tubotympanic Otitis and Attic Retraction Pockets Factors Associated With Recurrence

OBJECTIVES To correlate the recurrence of temporalis fascia graft perforation and retraction in adults and children after tympanoplasty for chronic tubotympanic otitis and deep attic retraction pockets with age, pathologic process, mucosal lesions, mucociliary transport time, chronic sinusitis, and lateral attic wall reconstruction. DESIGN Retrospective study. SETTING Tertiary referral center. PATIENTS Two hundred seventy-four adult ears and 41 child ears were operated on for chronic tubotympanic otitis, 50 adult ears were operated on for traumatic tympanic membrane rupture, and 56 adult ears were operated on for attic retraction pockets. INTERVENTIONS Underlay tympanoplasty with or without mastoidectomy and lateral attic wall reconstruction for attic retraction pockets. Mucociliary transport time was investigated using saccharin testing. MAIN OUTCOME MEASURES Recurrent perforation, recurrent attic retraction, and temporalis fascia graft retraction were evaluated. RESULTS Higher incidences of recurrent perforation were found in adults operated on for tubotympanic otitis vs traumatic tympanic membrane rupture (P = .02) and in children (P = .004), especially those 9 years and younger (P = .02). A risk factor in adults was chronic sinusitis (risk ratio, 35.0; 95% confidence interval, 32.1-38.2; P = .004). Temporalis fascia graft retraction correlated with slower mucociliary transport time in adults (P < .001). A lower incidence of recurrent attic retraction was associated with lateral attic wall reconstruction (P < .001). CONCLUSIONS Recurrent temporalis fascia graft perforation after tympanoplasty for tubotympanic otitis may be related to age and coexisting chronic sinusitis. Temporalis fascia graft retraction correlates with slower mucociliary transport time in the eustachian tube. Lateral attic wall reconstruction minimizes recurrent attic retraction in adults.

Predictors for sensorineural hearing loss in patients with tubotympanic otitis, cholesteatoma, and tympanic membrane retractions.

Objective To determine predicting value of otitis type, age, gender, ear suppuration, disease duration, mucosal changes, cholesteatoma spreading, labyrinthine fistula, size, localization of tympanic membrane perforation, type and stage of its retraction and ossicular chain disruption with sensorineural hearing loss in patients with tubotympanic otitis, cholesteatoma, and tympanic membrane retractions. Study Design Retrospective case review study. Setting Tertiary referral center. Patients Approximately 264 adult patients with unilateral chronic ear disease, 60 adult patients with tympanic membrane retractions, 78 with cholesteatoma, and 126 with tubotympanic otitis. Interventions Otomicroscopy, pure tone audiometry, impedancemetry were carried out preoperatively. Wall up, wall down tympanoplasty, or two-stage surgery was applied depending on pathology. Main Outcome Measure Bone conduction thresholds for 512 to 4,096 Hz. Results Mean values of bone conduction thresholds for frequencies 512 to 4,096 Hz were significantly higher in otitis groups than in healthy ears (p = 0.000), without differences between the groups. Ossicular disruption correlated with sensorineural hearing loss in cholesteatoma and tubotympanic otitis for all frequencies; long incus process destruction in tubotympanic ears showed strong negative correlation with sensorineural hearing loss for 512 to 2,048 Hz (linear regression coefficient, intercept was −2.84, −2.48, and −2.41; p = 0.0024, 0.0207, and 0.0076, respectively). Perforation size correlated with sensorineural hearing loss for 512 to 2,048 Hz in tubotympanic otitis (Log regression p = 0.0008, 0.0252, and 0.0267; odds ratio, 1.13, 1.11, and 1.06). Atelectasis correlated with sensorineural hearing loss for 4,096 Hz (p = 0.022). Conclusion Predictors for sensorineural hearing loss in chronic otitis are otitis itself, age, ossicular disruption, especially of long incus process, extensive labyrinthine fistula, perforation size, and type of retraction.

Expression of toll-like receptors 2, 4 and nuclear factor kappa B in mucosal lesions of human otitis: pattern and relationship in a clinical immunohistochemical study.

Objectives: The objectives were to detect and compare the expression of toll-like receptors (TLRs) 2, 4 and nuclear factor kappa B in mucosal lesions of chronic otitis. Methods: Fifty-five tissue samples obtained from children and adults operated on for otitis were investigated by semiquantitative immunohistochemical methods using polyclonal antibodies for TLR 2, 4 and NFkB. Kruskal–Wallis, Mann–Whitney, and Kendall’s tau rank correlation tests were used. Results: Stronger expression of TLR2, 4 was found in inflamed mucosa than in the control for children and adults (TLR2: H = 23.86, P < .001; TLR4: H = 22.80, P < .001) (TLR2: H = 17.53, P < .001; TLR4: H = 11.99, P < .001); in cholesteatoma perimatrix compared to tubotympanic lesions in children (TLR2: H = 11.06, P = .004; TLR4: H = 10.61, P = .005) and adults (TLR2: H = 10.73, P = .013; TLR4: H = 9.65, P = .021). No differences were found in NFkB expression (H = 0.042, P = .99). Significant correlations were found for all pairs of molecules in cholesteatoma and tubotympanic mucosa of adults (TLR2, 4: P = .002, P < .001; TLR2-NfkB: P = .032, P = .021; TLR4-NFkB: P = .035, P = .0013), only TLR4-NFkB in tubotympanic otitis of children (P = .026). Conclusions: Toll-like receptors 2, 4 and NFkB mediate inflammation in cholesteatoma and mucosal lesions of tubotympanic otitis in children and adults. Significant correlations between all pairs of molecules in all samples were detected in adults, but only TLR4-NFkB in children.

Polymorphisms in Toll-like receptors 2 and 4 genes and their expression in chronic suppurative otitis media

OBJECTIVE Toll-like receptors (TLRs) have a prominent role in inducing innate immune response. It has been suggested that regulation of TLRs is involved in the pathogenesis of chronic otitis media. TLR 2 and TLR 4 polymorphisms were connected with susceptibility to acute otitis and chronic otitis with effusion. The objective of this study was to establish expression of TLR 2 and 4 on middle ear mucosa in different types of chronic suppurative otitis media (CSOM), and the influence of gene polymorphisms TLR 2 Arg753Gln and TLR 4 Thr399Ile and Asp299Gly to susceptibility to CSOM. MATERIAL AND METHODS Middle ear mucosa and full blood samples were obtained from 85 patients with chronic suppurative otitis media with and without cholesteatoma. Control group for mucosal TLR expression consisted of 71 samples of middle ear mucosa taken from patients with otosclerosis, and control group for DNA polymorphism consisted of 100 full blood samples in healthy subjects. DNA polymorphism detection was done with restriction fragment length polymorphism in RT PCR. Expression of TLR 2 and 4 was determined with immunohistochemical staining. RESULTS TLR 2 and TLR 4 expression on the middle ear mucosa was not influenced by age of the patients with chronic otitis media. Incidence of TLR 2 Arg753Gln polymorphism was significantly higher in patients with chronic otitis media, compared to control group. Significant association between TLR 2 Arg753Gln polymorphism and different types of mucosal changes in patients with chronic otitis media was established. TLR 2 and 4 expression on experimental group mucosa was significantly different compared to control group, where there was no expression (p=0.000). Strong dependence of TLR 2 and TLR 4 expression on middle ear mucosa with different mucosal changes and immunohistochemical activity after staining was detected. CONCLUSION Certain polymorphisms in TLR genes could be indicative for susceptibility to chronic otitis media. Expression of TLR 2 and 4 on middle ear mucosa was more dependable on different types of mucosal changes and type of CSOM than on bacteria found in the specimens. This can indicate that the type of mucosal changes are closely correlated with TLRs activity in middle ear.

Enzymatic study of tonsil tissue alkaline and acid phosphatase in children with recurrent tonsillitis and tonsil hypertrophy

OBJECTIVE Indications for tonsillectomy in recurrent tonsillitis are defined according to the number of episodes of acute bacterial infections in a year. However, little is known about the tonsil immune competence status in patients presenting with recurrent tonsillitis with either hypertrophied or atrophied tonsils, or in patients presenting with obstructive sleep apnoea. In this study we examined the tonsil immune status in children with 3-5 acute recurrent infections a year and in children with obstructive sleep apnoea by comparing the activity of tonsil and adenoid tissue nonspecific alkaline and acid phosphatase. METHODS Specific activity of tonsil and adenoid tissue nonspecific alkaline and acid phosphatase was investigated in children who underwent tonsillectomy and adenoidectomy for recurrent infection (72 children) and for obstructive sleep apnoea (10 children). Tissue enzyme activities were measured using p-nitrophenylphosphate as a substrate. Tissue samples were examined by the haematoxylin-eosin histological technique. Statistical analyses were performed using SPSS v. 16 software. RESULTS The tissue nonspecific alkaline phosphatase activity was similar in hypertrophied tonsils in the recurrent infection group and in the obstructive sleep apnoea group (3.437+/-1.226 and 3.978+/-0.762 U/mg of protein, respectively). The enzyme activity in both hypertrophied tonsil groups was significantly higher as compared to atrophied tonsils in the recurrent tonsillitis group, p=0.021 and p=0.006, respectively. The enzyme activity was significantly higher in the adenoids compared to the tonsils from all three groups. Contrary to this, no significant differences were noticed for tonsil and adenoid acid phosphatase activities among the groups. CONCLUSION Similar acid phosphatase activity in all three groups implies that all three groups have preserved antigen presenting cell activity. In patients with hypertrophied tonsils similar tissue nonspecific alkaline phosphatase activity suggests preserved B cell tonsil immune activity, regardless of the pathology. Patients with atrophied tonsils had significantly lower alkaline phosphatase activity, indicating relative tonsil B cell immune deficiency. Thus, different immunological status in patients presenting with hypertrophied vs. atrophied tonsils could point to a different underlying pathophysiologic mechanism of the disease.

Altered immunoregulations in otosclerosis: presence of autoantibodies in otosclerotic sera samples.

A current concept of the etiopathogenesis of otosclerosis is an immune response. The purpose of this study was to determine if autoantibodies were present in sera samples from patients with known otosclerosis. Organ non-specific total antinuclear antibodies (tANA) were determined in 98 sera samples by the immunofluorescent method in 47.9% of otosclerotic patients versus 5% in controls. The most frequent specific antinuclear antibody was antibody to native deoxyribonucleinic acid and antibody to ribonucleoprotein. Tissue-specific antibodies to native-collagen type II molecule (ACA II) were determined by counter-immunoelectrophoresis in the same sera samples and were detected in 54% versus none in healthy sera. There was no correlation between the presence of these two autoantibodies. In patients with tANA present, a statistically significant depletion of cochlear function was noted. The presence of ACA II showed no connection with hearing loss. The present study showed some alteration in immunoregulatory markers in otosclerotic patients and the possibility that ANA may play a role in the pathogenesis of otosclerosis-induced perceptive deafness.

Clinical characteristics of the eardrum retraction pocket

Development of the eardrum retraction pocket, as pathologic finding, depends on Eustachian tube dysfunction, onset of the middle ear infection and site of development of retraction on the eardrum. The study is aimed at: 1. Determining the incidence of eardrum retraction pocket and cholesteatoma within it, as well as at the degree of eardrum retraction; 2. Determining of association between eardrum retraction pocket and changes of the eardrum mucosaand parstensa of the tympanic membrane; 3. Determining of onset and intensity of the bone destruction in eardrum retraction pocket; 4. Examining of Eustachian tube function based on time of mucocilliary transport according to the type of the eardrum retraction pocket. The study is based on the retrospective analysis of the results obtained from the patients treated at the Institute of Oto-Rhino-Laryngology and Maxillofacial Surgery Clinical Centre of Serbia in Belgrade for the diagnosis of the chronic suppurative otitis who underwent otosurgical procedures during the six-year period, from 1996-2001. In our series of 540 patients subjected to otosurgical treatment, the incidence of the retraction pocket of the eardrum was 11.23%. Onset of more severe degree of eardrum retraction was most frequent in the attic. Cholesteatoma was detected in 82.2% of patients of the group with the attic-retraction pocket of the eardrum, as well as in 25% of patients of the group of tensa-sinus retraction pocket of the eardrum. Atrophic changes of the tympanic membrane pars tensa were detected in almost all tensa-sinus retraction pockets of the eardrum. Approximately one half of the attic-retraction pockets of the eardrum were accompanied by eardrum atrophy. Bone destruction of the auditory ossicles was limited to the long process of incus and superior structures of stapes. Time of the mucocilliary transport was significantly longer (p<0.01) in attic-retraction pocket of the eardrum than in tensa-sinus retraction pocket of the eardrum, indicating significance of tube in development of attic-retraction pocket of the tympanic membrane. Reversible changes of the middle ear mucosa were evidenced in three quarters of the tensa-sinus retraction pockets of the eardrum indicating that inflammation is the major factor influencing onset of tensa-sinus retraction pocket of the eardrum.

Pars tensa retractions without cholesteatoma in children: predictors for ossicular chain destruction, air conduction thresholds, and postoperative retractions.

Objective Determine predictive values of preoperative stages of pars tensa retractions, coexisting attic retraction and preoperative air conduction for ossicular destruction in isolated and combined pars tensa retraction, and predictors for successful tympanic grafts after surgery. Study Design Prospective case series study. Settings Tertiary referral center. Patients Forty-eight children ears without cholesteatoma were included in the study: 23 with isolated pars tensa retraction (median age, 11), 25 with combined pars tensa and attic retractions (median age, 13). Intervention(s) Otomicroscopy, pure tone audiometry, and impedancmetry were carried out preoperatively. Three surgical procedures for isolated retractions were used: ventilation tube insertion alone or together with fascia graft or cartilage graft. Two surgical procedures for combined retractions were used: ventilation tube insertion alone and with cartilage graft. Main Outcome Measures Incidence of ossicular destruction, postoperative retraction of the grafts. Results Stage of pars tensa retraction and preoperative air conduction thresholds do not predict long incus process defect in isolated group. Coexistence of an attic retraction predicts combined, long incus process and stapes superstructure defect (Chi = 3.943, p = 0.047, OR = 12.00). Retractions of grafts are predicted by mode of surgery, favoring cartilage graft (isolated group: Chi = 4.306, p = 0.0372,OR = 4.69; combined group Chi = 4.7836, p = 0.0287, OR = 0.1364). Stage of pars tensa retraction predicts poor outcome of fascia graft (Chi = 4.5347, p = 0.0332, OR = 12.00). Conclusion Absence of correlation between stage of pars tensa retraction and air conduction thresholds with ossicular defects justifies surgical exploration of the auditory ossicles, even in lower stages of retraction. Combined ossicular defect is expected in combined retractions. The usage of cartilage graft proved to be more appropriate.