Influence of proton pump inhibitor therapy on occurrence of voice prosthesis complications.

PURPOSE: It has been shown that the reflux of the gastric content to the proximal oesophagus influences incidence of voice prosthesis (VP) complications in laryngectomized patients. We conducted prospective randomised study to investigate the relationship between pepsin concentration in saliva and occurrence of VP complications before and after 3 months of proton pump inhibitor (PPI) therapy. METHODS: 60 laryngectomized patients with VP and 30 controls were included in the study. Saliva samples were collected in the morning and concentration of pepsin were measured by Human Pepsin (PG) ELISA kit. Thirty-Four (57%) patients reported one or more VP complication and were randomised in two groups, with and without PPI therapy, 40 mg pantoprazole per day for 3 months. RESULTS: Patients who had longer time since last VP change had higher incidence of periprosthetic and transprosthetic leakage and Candida colonisation. Pepsin was found in all saliva samples. Median saliva pepsin concentration level did not significantly differ between laryngectomized patients and control subjects, or between patients with and without VP complications, and there was no correlation between saliva pepsin concentration levels and type of VP complication. After 3 months therapy, there was no difference in median saliva pepsin level or incidence of VP complication between patients with and without PPI therapy. CONCLUSION: Although reflux was proposed to be associated with VP complications and pepsin was proven as a most sensitive and specific marker of EER, we did not find any statistically significant correlation between pepsin levels and occurrence of VP complications. A 3 months 40 mg pantoprazole therapy was ineffective in reduction of VP complications in our study group.

Tongue metastasis as an initial presentation of renal cell carcinoma.

Aim Distal metastases to oral cavity are very rare. Adenocarcinoma, renal cell carcinoma (RCC) and squamous cell carcinoma are the most common metastatic tumours. The aim of this study was to assess the diagnostic relevance of metastatic renal cell carcinoma on tongue manifestations in large patient series. Methods A patient with distal RCC metastases to the tongue and neck lymph nodes as the first manifestations of malignancy was presented. Also, all reports described during 106-year period relating to distal RCC metastasis to the tongue were evaluated. Results In the presented patient, initial presentation of RCC was metastasis to the tongue. Three months after nephrectomy, tongue tumour resection and radical neck dissection were performed. Histopathological analysis confirmed RCC metastasis. Postoperatively, the patient underwent radiotherapy and polychemotherapy. Tongue metastasis from RCC is extremely rare with only 51 cases reported during the 106-year period. In only 7 patients tongue metastasis was reported as an initial presentation of RCC. Conclusion The RCC metastasizing to the tongue is extremely rare and thus it poses a diagnostic challenge especially when it is the first sign of malignancy. Therapeutic decisions should maximize patient comfort and minimize morbidity considering the poor long-term prognosis.

Expression of polysialic acid in primary laryngeal squamous cell carcinoma.

AIMS: Expression of polySia is associated with metastatic dissemination and progression of various malignant diseases. In particular, it may contribute to tumorigenesis by a negative modulatory effect on cellular signaling cascades responsible for cellular migration, differentiation and proliferation. In this study, we investigated the expression of polySia in primary metastatic and non-metastatic laryngeal squamous cell carcinoma (LSCC) tumor tissues and its potential impact on the LSCC progression. MAIN METHODS: The expression of polySia in metastatic and non-metastatic primary laryngeal squamous cell carcinoma (LSCC) tumor biopsy specimens was investigated by immunohistochemistry, while the expression of polysialyltransferase IV (ST8SiaIV)(), fibroblast growth factor receptor 1 (FGFR1), extracellular signal regulated kinases 1 and 2 (Erk 1/2) and c-Raf was tested in metastatic and non-metastatic primary tumor tissues (including the corresponding non-tumor control tissues) by Western blot analysis. KEY FINDINGS: The expression of polySia was detected in LSCC biopsies specimens with generally stronger immunoreactivity in non-metastatic tumor LSCC sections and in histologically undifferentiated tumors. Also, increased polySia expression was observed in adjacent histologically unaltered laryngeal tumor-associated tissue of the metastatic sections. In addition, we provide an evidence of increased polysialyltransferase IV (ST8SiaIV) expression, involved in polySia synthesis in both metastatic and non-metastatic primary tumors which is accompanied by decreased levels of FGFR1, Erk 1/2 and c-Raf. SIGNIFICANCE: We present for the first time the evidence for the polySia expression in LSCC biopsies specimens which suggests its potential impact on initial steps of LSCC malignant transformation.

Acoustic Reflex and House-Brackmann Rating Scale as Prognostic Indicators of Peripheral Facial Palsy in Neuroborreliosis.

Lyme borreliosis is a vector-borne infectious disease characterized by three disease stages. In the areas endemic for borreliosis, every acute facial palsy indicates serologic testing and implies specific approach to the disease. Th e aim of the study was to identify and confirm the value of acoustic refl ex and House-Brackman (HB) grading scale as prognostic indicators of facial palsy in neuroborreliosis. Th e study included 176 patients with acute facial palsy divided into three groups based on serologic testing: borreliosis, Bell's palsy, and facial palsy caused by herpes simplex virus type 1 (HSV-1). Study patients underwent baseline audiometry with tympanometry and acoustic reflex, whereas current state of facial palsy was assessed by the HB scale. Subsequently, the same tests were obtained on three occasions, i.e. in week 3, 6 and 12 of presentation. Th e patients diagnosed with borreliosis, Bell's palsy and HSV-1 differed according to the time to acoustic refl ex recovery, which took longest time in patients with borreliosis. Th ese patients had the highest percentage of suprastapedial lesions at all time points and recovery was achieved later as compared with the other two diagnoses. Th e mean score on the HB scale declined with time, also at a slower rate in borreliosis patients. Th e prognosis of acoustic refl ex and facial palsy recovery according to HB scale was not associated with the length of elapsed time. The results obtained in the present study strongly confirmed the role of acoustic reflex and HB grading scale as prognostic indicators of facial palsy in neuroborreliosis.

Small nonfunctional parathyroid cysts: single institution experience.

Parathyroid cysts (PCs) account for less than 1% of all parathyroid lesions and are most commonly located along thyroid lobes, rarely at ectopic sites. PCs are important because they can pose a differential diagnostic challenge against other cystic formations of the neck. PCs can be functional (elevated serum parathyroid hormone level) and nonfunctional. Four cases of nonfunctional PCs are presented. All four female patients underwent physical examination and ultrasonography of the neck with ultrasound-guided fine-needle aspiration biopsy (UG-FNA). The material thus obtained was stained by the standard May-Grünwald-Giemsa method. Parathyroid hormone level was determined in aspirate and serum, along with serum levels of total calcium, inorganic phosphates. In two asymptomatic patients, remission occurred after initial aspiration biopsy; one patient had compression syndrome with vocal cord paresis that required surgical treatment; and one patient had cyst recurrence that was surgically removed. Cystic neck masses can pose a major differential diagnostic problem considering different approach, treatment method, and preoperative and postoperative follow up. Surgical treatment is necessary in case of functional and large nonfunctional PCs (due to compression syndrome), whereas individualized therapeutic approach is used in case of small nonfunctional PCs. Ultrasonography with UG-FNA, cytologic analysis of the material obtained, and determination of parathyroid hormone level in aspirate and serum are crucial for making an accurate diagnosis.

[[GUIDELINES FOR THE PREVENTION, MONITORING AND THERAPY OF CHRONIC KIDNEY DISEASE-METABOLIC BONE DISEASE IN PATIENTS WITH CHRONIC KIDNEY DISEASE].]

Chronic kidney disease (CKD) is a systemic disease with numerous complications associated with increased morbidity and mortality. Chronic kidney disease-metabolic bone disease (CKD-MBD) starts at early stages of CKD with phosphorus accumulation and consequent initiation of numerous events that result with the development of secondary hyperparathyroidism with changes on bones and extraskeletal tissues. The most important and clinically most relevant consequences of CKD-MBD are vascular calcifications which contribute to cardiovascular mortality. Patients with the increased risk for the development of CKD-MBD should be recognized and treated. Prevention is the most important therapeutic option. The first step should be nutritional counseling with vitamin supplementation if necessary and correction of mineral status. Progression of CKD requires more intensive medicamentous treatment with the additional correction of metabolic acidosis and anemia. Renal replacement therapy should be timely initiated, with the adequate dose of dislaysis. Ideally, preemptive renal transplantion should be offered in individuals without contraindication for immunosuppressive therapy.

Postoperative quality of life after two different methods of tonsillectomy.

BACKGROUND AND OBJECTIVES: Tonsillectomy is a very painful procedure. Pain may be severe, and patients are often unable to perform in school or eat regular food for a number of days after the surgery. The aim of this study was to compare the quality of life after undergoing two different surgical techniques of tonsillectomy, harmonic scalpel and classic tonsillectomy with bipolar cauterization. DESIGN AND SETTING: Prospective randomized double-blind, clinical trial study conducted in the ENT Department, Dr. Josip Bencevic General Hospital, Slavonski Brod, Croatia. PATIENTS AND METHODS: Data were collected, according to the type of operation, on pain persistence and intensity and returning to normal eating with tonsillectomy patients during the first seven postoperative days. Group A consisted of 50 children submitted to classic tonsillectomy with bipolar cauterization, while group B included 50 children operated on using the harmonic scalpel. Data on pain intensity were obtained using pain measuring scales adjusted to children's age (Faces scales, visual analog scale). The first day of normal oral food intake was recorded. RESULTS: The analysis of variance revealed that the grade of pain significantly differs by a surgical technique employed, and that it significantly varied over the first seven postoperative days. The pain was more severe after undergoing the harmonic scalpel technique and children started to eat later compared with the classic tonsillectomy. CONCLUSION: The classic tonsillectomy method with bipolar cauterization is the method of choice due to lower postoperative pain levels and sooner normal eating. The quality of life is better after undergoing the classic tonsillectomy method.

Necrotizing fasciitis of the neck after total laryngectomy.

Necrotizing fasciitis (NF) is an unusual, life threatening, rapidly advancing infection characterized by widespread fascial and subcutaneous tissue necrosis and gangrene of the skin. It most commonly affects the extremities, abdominal wall and perineum, whereas cervical NF is rare. NF of the head and neck is often caused by both aerobic and anaerobic microorganisms found in the upper aerodigestive tract. Usually, cervical NF originates from odontogenic, tonsillar and pharyngeal infection, and it is very rarely a complication of surgical procedure. Without immediate surgical treatment, cervical NF leads to mediastinitis and fatal sepsis. There is only one case of cervical NF after total laryngectomy described in the literature. We report two cases of cervical NF after total laryngectomy, selective neck dissection and primary vocal prosthesis insertion. In both cases, the infection spreads to thoracic region and in one of them NF was associated with Lemierre's syndrome, i.e., thrombosis of the internal jugular vein. In both patients, vocal prosthesis was inserted during the infection and did not influence the healing process.

The significance of Helicobacter pylori in patients with nasal polyposis.

AIM: To determine the presence of Helicobacter pylori in nasal polyps and the transmission of H. pylori from stomach to nasal polyps. METHODS: In a prospective, controlled clinical research, 35 subjects with nasal polyps and 30 controls with concha bullosa (CB) were involved, and had been subjected to endoscopic sinus surgery (ESS). In the biopsies of removed polyps and CB, polymerase chain reaction (PCR) was used for detecting the H. pylori DNA. Blood samples of the test and control group were evaluated for H. pylori immunoglobulin (Ig) G and A antibodies by ELISA. The test and control group underwent esophagogastroduodenoscopy with taking biopsies from the stomach for PCR detection of H. pylori DNA. RESULTS: In blood samples, specific IgG and IgA antibodies to H. pylori were found in 30 (85.71%) of 35 polyp patients and in 16 (53.33%) of 30 controls. In 10 (28.57%) of 35 patients H. pylori DNA was identified in the nasal polyp tissue, but it was not detected in the CB specimens. H. pylori DNA was found in the stomach mucosa samples of all test and control group of subjects. Significant statistical difference was found in the H.pylori specific IgG and IgA between the test and control group (p less 0.006) and between the polyp and control biopsy specimens of H. pylori DNA by PCR (p less 0.001). CONCLUSION: This research points to the colonisation of nasal polyps with H. pylori, the transfer of H. pylori from stomach to nasal polyps and potential role of H. pylori in emergence of nasal polyps.

Twenty one months of frontal sinus stenting.

The success of a frontal sinus endoscopic or external operation depends on the postoperative stenosis of the frontal sinus ostium. Formation of a stenosis can be prevented by placing a stent in the frontal sinus ostium. The period optimal for leaving the stent in the sinus ostium is yet to be established, but experts recommend a maximum six months period. This case report presents a female patient who underwent an endoscopic bilateral frontal sinus operation in 2005. Postoperatively, she developed a stenosis of the right frontal sinus recess which resulted in a series of reoperations. At the end of 2009, a Medtronix Xomed Incl Parell T-Frontal Stent was inserted by external approach. At the 21-month followup, the patient was still free from discomfort with the stent normally placed. Proper hygiene, regular monitoring and endoscopic cleansing of the patient's stent resulted in the sinus orderly functioning with the stent placed within its ostium, without incrustation or breathing difficulties and headaches as a consequence.

Morphometry in differential diagnosis of pathologically altered parathyroid glands: adenoma and hyperplasia.

Simple morphological identification of a sample as parathyroid gland tissue is not always sufficient for optimal patient treatment. Instead, patients with parathyroid gland lesions that increase the risk of disease relapse should be identified. To assess the possibility of differentiating adenoma from hyperplasia in preoperative material by use of computerized morphometric analysis in order to enable better preoperative work-up in patients with hyperparathyroidism. Samples obtained by US guided fine-needle aspiration biopsy of 67 parathyroid glands without known histopathologic diagnosis were dried and stained by May-Grünwald-Giemsa. Fifty nuclei per sample were analyzed and designated automatically with manual correction using image analyzer and specific software. The area, circumference, convexity, minimal and maximal radius, length and width, and factors of regularity, i.e. form factor and factor of nucleus elongation, were determined for each nucleus. Basic descriptive parameters and measures of variability (variation coefficient and standard deviation) were calculated for each continuous variable. The correlation of continuous variables was analyzed by use of Mann-Whitney test. Computer analysis of cell image classified the cell nuclei into two groups. The area, circumference, minimal radius, convexity and width of the nuclei showed higher values in the hyperplasia group as compared with the adenoma group. Standard deviation also showed higher values of each of the study parameters in the former group. Our own observations and subjective assessment of variations in nucleus size to represent substantial characteristics differentiating parathyroid adenoma and hyperplasia in cytologic smear were quantitatively verified by the use of objective morphometric measurement and should therefore be considered valid parameters on differentiating these two entities.

Analysis of saliva pepsin level in patients with tracheoesophageal fistula and voice prosthesis complications.

The aim of this crossectional study was to investigate the relationship between pepsin concentration in saliva and the occurrence of tracheoesophageal fistula (TEF) complications and voice prosthesis (VP) complications, after total laryngectomy and VP implantation. We assessed the concentrations of pepsin in the saliva of 41 laryngectomized patients and correlated it with the incidence of TEF complications (periprostethic leakage, atrophy, esophageal mucosa hypertrophy, granulations, fistula enlargement, and VP dislocation), VP complications (transprosthetic leakage, Candida infection) and voice quality. Pepsin levels were measured by enzyme-linked immunoadsorbent assay (ELISA). Voice quality was assessed by Harrison-Robilard--Schultz (HRS) scale. In all, 17 (42%) patients had complications. All of them had TEF complications, whereas VP complication, together with TEF was found in 9 (22%) patients. We found no significant correlation between adjuvant radiotherapy and TEF complications. Most of patients, 30 (73%), had positive pepsin level in saliva. Median value of pepsin concentration in all patients was 4.8 (range 81.7). Median pepsin concentration was higher in patients free of TEF or VP complications (6.6, range 81.7 vs. 3.2, range 19.3) but that difference was not statistically significant (Mann-Whitney test, Z--1.562, p = 0.118). In addition, statistically insignificant negative correlation between pepsin levels and voice quality measured by HRS scale (Spearman's rho, p > 0.05). Although reflux was proposed as cause of TEF complications and pepsin has been proven as a most sensitive and specific marker of ekstraesophageal reflux, we did not find any statistically significant correlation between pepsin levels and occurrence of TEF or VP complications.

Harmonic scalpel surgical treatment of the tongue angioleomyoma--case report and review of the literature.

Angioleiomyoma is benign soft tissue tumor composed of smooth muscle cells and vascular endothelium, characterized with slow growth, unspecific symptoms and rare malignant transformation. It is very rare in the head and neck region and complete surgical excision is the gold standard for diagnosis and treatment. We present a very rare case of angoleomyoma of the tounge base treated with partial glosectomy with harmonic scalpel which shortened surgical procedure, reduced bleeding and postoperative complications.

Apocrine carcinoma of the scalp with aggressive clinical course--a case report and review of the literature.

Primary cutaneus apocrine carcinoma is a rare malignancy with about 50 cases reported in the literature. Axilla is the most common site of occurrence, but locations like scalp, anogenital region, ear canal, chest, wrist, finger and eyelid have been described. The neoplasm presents itself as an asymptomatic, slow-growing, solid or cystic mass that varies in color. Most patients have a history of a long-standing neoplasm before the diagnosis is made. The disease is considered to have an indolent clinical course with favorable outcome although more than half of reported patients had regional lymph node metastases at the time of diagnosis. Systemic dissemination to lung, bones, liver and brain is extremely rare with only 14 cases documented in the literature. Wide surgical excision with lymph node dissection upon confirmation of the lymph node metastases remains the only curable treatment. Care and management of the disseminated disease is still challenging. We report a case of a 65-year-old woman with a very aggressive apocrine carcinoma of the scalp prone to local recurrence and distant metastases to lung and bones.

Posttraumatic subperiosteal orbital hematoma.

BACKGROUND: Subperiosteal orbital hematoma (SOH) is a rare finding after midface trauma, causing compartment syndrome within the orbit. It should be consideration in the differential diagnosis of any case of proptosis and vertical globe displacement. PATIENTS: We present two patients with SOH treated by surgical evacuation and drainage. RESULTS: In both the hematomas resolved completely and uneventfully. CONCLUSION: Being a safe and simple method, surgical decompression combined with drainage enables complete evacuation of the blood clot and prevents possible sequelae. This method should be considered even in cases without significant visual impairment.

Gastric adenocarcinoma metastases to the alveolar mucosa of the mandible: a case report and review of the literature.

Malignant tumours rarely metastasize to the oral cavity. When they do, such metastases may arise from various locations including the lung, breast, kidney, prostate and colon. Soft tissue oral metastasis from gastric adenocarcinoma is extremely rare, and limited information exists regarding the presentation and work-up of metastatic gastric carcinoma into the oral soft tissue. We present an unusual case of a 70-year-old man and review the records of 17 cases of soft tissue oral metastasis from gastric carcinoma in the English and Japanese literature. Metastatic lesions from all sources are typically diagnosed in patients in their fifth to seventh decade, with the most common sites of soft tissue metastasis being the gingiva and alveolar mucosa of the mandible. In almost one quarter of patients a metastatic lesion in the oral cavity is the first manifestation of an undiscovered primary malignancy. They grow rapidly and tend to bleed and ulcerate. Because of their rarity and clinical characteristics, gastric metastatic tumours in the oral cavity are challenging to diagnose. Inflammatory and reactive lesions are common in the oral cavity and they should be considered in the differential diagnosis. Careful examination with a high degree of clinical suspicion, as well as a multidisciplinary approach is suggested.

Mechanical ventilation in chronic obstructive pulmonary disease patients, noninvasive vs. invasive method (randomized prospective study).

Acute respiratory failure due to chronic obstructive pulmonary disease (COPD) presents an increasing problem throughout the world. The aim of this study was to compare invasive and non-invasive mechanical ventilation (MV) for patients with COPD. A prospective, randomized trial was performed in a multidisciplinary intensive care unit for the period of 36 months and included 156 patients with COPD. MV procedure was performed using standard methods, and was applied as either invasive MV (IMV) or noninvasive MV (NIMV). Patients were randomized in two groups for application of MV using closed, nontransparent envelops. Comparison was made based on patient characteristics, objective parameters on admission and 1h, 4h, 24h, and 48h after admission and based on treatment outcome. We have confirmed that NIMV method is superior to IMV for patients with COPD. MV duration NIM:IMV was 94:172 hours, p < 0.001, time spent in Intensive Care Unit 120:223 hours, p < 0.001. Ventilator associated pneumonia 5(6%):29(37%), p < 0.001. The advantage of NIMV in COPD patients, especially in the early stages was confirmed.

Duke Treadmill Score in prioritizing patients for coronary angiography: retrospective study of a Croatian regional hospital.

Aim of the study was to determine the potential of Duke Treadmill Score (DTS) in prioritizing patients for coronary angiography in a transitional country clinical setting. We analyzed 114patients with suspected stable coronary artery disease who underwent exercise treadmill testing, and coronary angiography in Slavonski Brod General Hospital. DTS was calculated from treadmill test as: exercise time--(5 x ST deviation in mm)--(4 x exercise angina). Regarding the score, patients were grouped into three groups of risk for coronary artery disease: low risk, medium risk, and high risk patients. All patients underwent coronary angiography, and were grouped in accordance to the severity of the coronary artery disease into three groups: insignificant, significant, or severe coronary artery disease. All patients scored as high risk DTS had significant or severe coronary artery disease. Medium and low risk DTS patients had insignificant coronary artery disease in 50%, and 90% of cases, respectively. Medium risk patients with significant or severe coronary artery disease were significantly older, and had more frequent history of typical chest pain with higher number of episodes per week (P<0.05), whereas there were no differences regarding gender or presence of risk factors. There were no significant differences among medium risk patients regarding the severity of coronary artery disease in exercise time or ST deviation. However, the presence of limiting exercise angina in medium risk patients was significantly more related with significant and severe coronary artery disease (P<0.05). High risk DTS result showed great potential in stratifying patients for immediate coronary angiography. This scoring system may be used in prioritizing patients for coronary angiography in a transitional clinical setting.

Pulmonary compliance values provide prognosis in mechanically ventilated patients--a randomized prospective study.

Our aim was to evaluate the influence of static pulmonary compliance (Cst) on the choice of Mechanical Ventilation(MV) method and treatment outcome. A prospective, randomized trial conducted out at the multidisciplinary Intensive Care Unit (ICU) included 387 patients, randomized in two groups: noninvasive MV group and invasive MV group. Furthermore, each group was divided in two groups: Cst < or = 0.025 and Cst > 0.025 L/cm H2O. In patients with Cst > 0.025 L/cm H2O MV duration, noninvasive vs invasive, was 92 vs 114 h, p = 0.039, time spent in ICU 118 vs 164 h, p = 0.004. In patients with Cst < or = 0.025, MV duration was 141 vs 189 h, p < 0.001, time spent in ICU 190 vs 246 h, p = 0.001, all patients were intubated. Need for tracheostomy was 6 (11%) vs 39 (46%) patients, p = 0.005, and ICU mortality was 15 (26%) vs 21 (25%) patients. Statistical significance in favor of noninvasive method was confirmed in patients with Cst > 0.025 L/cm H2O in MV duration, time spent in ICU, need for tracheostomy and intubation rate. In the group with Cst < or = 0.025 no significant difference in treatment failure was recorded between the two MV methods.