A Bullet Lying Next to the Common Carotid Artery in the Neck of a Young Boy.

Penetrating neck trauma is most commonly caused by firearm discharge, and is potentially very dangerous, being associated with a high risk of mortality. A 12-year-old patient with a recent history of a gunshot wound to the neck was evaluated in detail; a bullet was located in close proximity to the left common carotid artery. Neck exploration was performed and the foreign body was removed without any complications. The management of the patient is discussed, as are contemporary approaches to the treatment of penetrating neck trauma. However, the choice of treatment for a stable patient with a penetrating neck injury remains controversial.

The evaluation of olfactory function in individuals with chronic halitosis.

Halitosis and olfactory dysfunction may disrupt an individual's quality of life remarkably. One may ask whether halitosis has effects on olfactory functions or not? Thus, the aim of this study was to evaluate the olfactory abilities of subjects with chronic halitosis evaluated using the measurements of volatile sulfur compounds. This study was carried out in 77 subjects, with a mean age of 40.1±13.3 years, ranging from 18 to 65 years. Forty-three participants were diagnosed as halitosis according to the gas chromatography results and constituted the halitosis group. Also, a control group was created from individuals without a complaint of halitosis and also who had normal values for volatile sulfur compounds. Each subject's orthonasal olfactory and retronasal olfactory functions were assessed using "Sniffin' Sticks" and retronasal olfactory testing. The results showed that odor threshold scores were lower in participants with halitosis compared with controls. Also, hyposmia was seen more common in the halitosis group than in controls. Moreover, a significant negative correlation was found between odor threshold scores and volatile sulfur compounds levels, particularly with hydrogen sulfide and dimethyl sulfide levels. The results suggest that the chronic presence of volatile sulfur compounds may have a negative effect on olfactory function.

Histological effects of inhaled corticosteroids and ß2-agonists on laryngeal mucosa in an allergic rat model.

OBJECTIVE: To constitute an animal model of laryngeal allergy and evaluate the laryngeal effects of inhaled corticosteroids and ß2-agonists on the laryngeal mucosa in an allergic rat model. STUDY DESIGN: Prospective randomized. SETTING: The Experimental Medical Research Institute (DETAE) at Istanbul University. SUBJECTS AND METHODS: Wistar Albino rats (n = 32) were sensitized with ovalbumin. Unsensitized rats (n = 8) served as controls. The rats were exposed to aerosolized ovalbumin (1%). On days 28 through 42, every 2 days preceeding ovalbumin exposure, rats were further exposed to aerosolized phosphate buffered saline (n = 8), fluticasone propionate (n = 8), salbutamol (n = 8), and combined salbutamol+fluticasone propionate (n = 8). Inflammatory cell infiltration was graded semi-quantitatively. The quantitative data included mast cell count and degranulation. Ultrathin sections were investigated under transmission electron microscope. RESULTS: The simultaneous and pairwise comparison of groups (Kruskal-Wallis) revealed statistically significant difference among groups at supraglottic level (critical P < .05, <.01) and no difference at glottic level. In ovalbumin+phosphate buffered saline exposed rats, the light microscopy of supraglottic mucosa revealed regular epithelium with severe inflammatory cell infiltration and increased mast cell count. Electron microscopy revealed increased mast cell degranulation. Increased inflammatory cell infiltration was detected along with reduced mast cell count among fluticasone propionate treated rats. Mild inflammatory cell infiltration was encountered in combined salbutamol+fluticasone propionate treated rats. CONCLUSION: This study supported the presence of localized allergic reaction in the supraglottic laryngeal mucosa through the observation of increased mast cell number and degranulation. It was also shown that inhaled corticosteroids increase inflammation whereas combined inhaled corticosteroids and ß2-agonists minimize allergic and inflammatory reactions in supraglottic laryngeal mucosa providing a safer therapeutic option.

Salivary and serum myeloperoxidase in obstructive sleep apnea.

OBJECTIVE: To assess the clinical utility of serum and saliva myeloperoxidase (MPO) and serum C-reactive protein (CRP) levels as markers of inflammation in obstructive sleep apnea (OSA). DESIGN: Prospective, controlled, observational study. SETTING: Snoring and respiratory sleep disorders centre at a tertiary hospital. METHODS: This study included 32 OSA-diagnosed patients and 24 age- and gender-matched healthy subjects following endoscopic airway evaluation and polysomnography. MAIN OUTCOME MEASURES: Saliva and serum MPO levels were analyzed by flow cytometry. Serum CRP levels were determined using a latex assay. The different groups were compared through parametric tests. Linear and logistic regression models using The Apnea-Hypopnea Index (AHI) as a dependent variable assessed the association of independent variables, including saliva and serum MPO levels, serum CRP levels, age, and body mass index (BMI). RESULTS: Salivary MPO and serum CRP levels were significantly higher in the OSA group compared to controls (p < .0001, p  =  .0001). A moderate positive correlation was detected between saliva MPO and AHI, the oxygen desaturation index, and sleep efficiency (p  =  .0001, p  =  .0001, and p  =  .0002, respectively) by excluding potential confounding factors (age and BMI). Salivary MPO and BMI levels were associated with AHI in a linear regression model (p < .0001) and found to be concordant variables with the presence of OSA. CONCLUSION: Increased salivary MPO levels in OSA subjects in this study support previously defined persistent local inflammation in these patients. Therefore, salivary MPO levels may be useful as oropharyngeal inflammatory markers in OSA patients.

Watch peripheral arterial tonometry in the diagnosis of obstructive sleep apnea: influence of aging.

OBJECTIVES/HYPOTHESIS: To investigate the consequences of aging and associated peripheral vascular tone impairment on peripheral arterial tonometry (Watch PAT)-based sleep and respiratory disturbance analysis in obstructive sleep apnea (OSA) diagnosis. STUDY DESIGN: Prospective, nonrandomized, clinical trial. METHODS: A total of 56 subjects with age ranges of 20 to 35 years (group I, n = 27) and 50 to 65 years (group II, n = 29) referred to the sleep laboratory for overnight polysomnography (PSG) with suspected OSA were enrolled. All patients underwent simultaneous overnight PSG and Watch PAT monitoring. The data derived from PSG and Watch PAT records, including apnea-hypopnea index (AHI), rapid eye movement (REM) AHI, non-rapid eye movement (NREM) AHI, oxygen desaturation index (ODI), mean O(2) saturation (mean O(2) sat), minimum O(2) saturation (min O(2) sat), sleep duration, and the percentages of NREM sleep stages 1-2 and 3 and of REM sleep were used for comparisons. The calculated ΔPSG-Watch PAT of the two groups were compared statistically. The correlations between the PSG-Watch PAT measurements in each group were assessed. RESULTS: The comparison of AHI, REM AHI, NREM AHI, ODI, mean O(2) sat, min O(2) sat, NREM sleep stage 1-2, and REM sleep ΔPSG-Watch PAT between the two groups did not reveal statistical significance. The difference between the two groups in terms of ΔPSG-Watch PAT of sleep duration and sleep stage 3 was statistically significant. CONCLUSIONS: In addition to the good agreement confirmed between PSG and Watch PAT data in each group, aging did not negatively impact Watch PAT recorded data in terms of included parameters, except the difference in ΔPSG-Watch PAT of sleep stage 3, which may be attributable to aging and impaired vascular tone.

Surfactant protein A and D in chronic rhinosinusitis with nasal polyposis and corticosteroid response.

BACKGROUND: Corticosteroids are a mainstay of treatment for chronic rhinosinusitis with nasal polyposis (CRSwNP). Data related to the effect of systemic methylprednisolone on surfactant protein (SP) expression in CRSwNP is limited. This study aimed to reveal the consequences of systemic methylprednisolone treatment on levels of SP-A and SP-D, which play a role in innate immunity, in patients with CRSwNP. METHODS: Twenty-one patients with CRSwNP were included in the study, along with 15 control patients scheduled for dacryocystorhinostomy. A polypoid tissue biopsy was taken under local anesthesia, and 15 CRSwNP patients were scheduled for endoscopic sinus surgery after 3 weeks of oral methylprednisolone. Posttreatment biopsies were performed perioperatively. Pre- and posttreatment endoscopic polyp grades were determined, as were symptom scores regarding nasal obstruction, headache, and nasal discharge using a visual analog scale (VAS). SP-A and SP-D levels were measured using enzyme-linked immunosorbent assay and the results were compared. RESULTS: All patients reported relief from clinical symptoms through VAS after methylprednisolone treatment. The posttreatment polyp grade was reduced (p < 0.0001). SP-A and SP-D levels did not yield a significant difference between CRSwNP patients and controls (p = 0.25 and p = 0.13, respectively). Statistically significant up-regulation was detected in SP-A and SP-D levels after oral methylprednisolone (p = 0.0002 and p = 0.0004, respectively). CONCLUSION: In this study, significant up-regulation of SP-A and SP-D was revealed in patients with CRSwNP after systemic steroid treatment. The role of SP-A and SP-D up-regulation in CRSwNP pathogenesis and therapeutic outcomes of corticosteroids have potential importance for the introduction of new therapeutic modalities that are more effective and produce fewer adverse effects.

Topical glucocorticoid reduces the topical decongestant-induced histologic changes in an animal model nasal mucosa.

OBJECTIVES/HYPOTHESIS: To investigate the histologic consequences of simultaneous nasal glucocorticosteroid and xylometazoline HCl administration in the rabbit nasal mucosa. STUDY DESIGN: Prospective randomized study. METHODS: Twenty New Zealand male rabbits were randomly placed into three groups: group I, control (n = 6); group II, xylometazoline HCl (n = 8); or group III, xylometazoline HCl-fluticasone furoate (n = 6). Group I received no treatment. Groups II and III received two intranasal puffs of xylometazoline HCl 0.5 mg/mL twice daily or two puffs of xylometazoline HCl 0.5 mg/mL twice daily plus one puff of 27.5 µg fluticasone furoate twice daily to each nostril (110 µg), respectively. At the end of 3 weeks, the rabbits were sacrificed. The mucosa of the nasal cavities was excised. Specimen sections (5 µm) were stained with hematoxylin and eosin, mucicarmine, and Gomori one-step trichrome and were examined under a light microscope. The presence of edema, congestion, inflammatory cell infiltration, nasociliary loss, epithelial and nerve-ending degeneration, and goblet cell increase were evaluated semiquantitatively (grades 0-3). RESULTS: Statistically significant differences were detected between groups II and III in terms of edema, congestion, inflammatory cell infiltration, nasociliary loss, and epithelial degeneration (P = .006, P = .049, P = .015, P = .014, and P = .049, respectively). Nerve-ending degeneration, goblet cell increase, and quantitative goblet and neutrophil cell counts did not yield statistically significant differences between groups II and III (P = .137, P = .580, P = .770, and P = .616, respectively). CONCLUSIONS: The combined simultaneous intranasal administration of xylometazoline HCl and fluticasone furoate appears to be beneficial in minimizing the long-term usage-associated congestion, edema, inflammatory cell infiltration, epithelial degeneration, and nasociliary loss in the rabbit model nasal mucosa.

Does nasal obstruction affect the articulation of plosive consonants?

OBJECTIVES: In this study, we investigated the impact of chronic nasal obstruction on articulation of the Turkish voiceless plosive (stop) consonants and examined the effect of the nose- and mouth-breathing on the articulatory characteristics of the specific speech sounds. PATIENTS AND METHODS: Twenty-one controls with nose-breathing and 20 patients with mouth breathing were included in this study. The nasal obstruction history of the patients was 10 to 22 years. In the mouth-breather group, intranasal pathologies except septal deviation and turbinate hypertrophy were excluded. The nose-breather subjects without nasal pathologies served as the control group. The subjects graded nasal obstruction through visual analog scale (VAS) from 0 to 10. The minimal cross-sectional area (MCA) and minimal cross-sectional volume (MCV) at the level of septal tubercle and the head of inferior turbinate were established to be 1 and 2 by acoustic rhinometry. Minimal cross-sectional volume was defined as the volume below the curve. The syllables [pa], [ta], [ka] uttered by the subjects were recorded for the spectrographic analysis. Voice onset time (VOT) was measured on wide-band spectrogram. RESULTS: The VOT value of /p/ was found lower and the VOT values for /t/ and /k/ were found higher in mouth-breathers compared to nose-breathers, while the difference was not statistically significant. The right and left-sided VAS values of the nasal obstruction group were significantly higher compared to controls (p=0.001). The right and left-sided MCA1, MCA2, MCV1 and MCV2 were found statistically different between the two groups. CONCLUSION: It was concluded that the articulation features of plosive consonants were not significantly affected by nasal obstruction.

Does the length of uvula affect the palatal implant outcome in the management of habitual snoring?

OBJECTIVES/HYPOTHESIS: To evaluate the impact of the uvular length on the efficacy of palatal implants in primary snoring. STUDY DESIGN: Prospective case series, tertiary hospital, snoring and respiratory sleep disorders center. METHODS: Forty subjects with inserted palatal implants and diagnoses of primary snoring were included. All met the inclusion criteria of age >18 years, body mass index <30, apnea-hypopnea index <5, tonsil grade <3, soft-palate length >25 mm, and Friedman tongue position <3 following clinical, endoscopic, and polysomnographic evaluation. Epworth sleepiness scale (ESS) and the snoring-intensity visual analogue scale (VAS) were recorded before and 9 months after the implant. Four subjects with extruded implants were excluded; the remaining 36 subjects were divided into two groups, Group I and Group II, with uvular lengths of ≤15 mm and >15 mm, respectively. The study assessed and compared subjective outcome measures including the partner's satisfaction (PS), partner's reported improvement (PRI), 50% VAS and ESS reduction, and subjective success (SS) defined as 50% VAS reduction. The Student t test, χ(2) test, and logistic regression models were used for statistical evaluation. RESULTS: SS (50% VAS reduction), PS, PRI, and 50% ESS reduction were significantly higher in Group I (P < .001, P = .0257, P = .027, P < .001). The overall SS, PRI, PS, and 50% ESS reduction were 33%, 78%, 50%, and 50%, respectively. The uvular length was found to be the determinant factor of SS (P = .005; odds ratio = 0.75), PRI (P = .039; odds ratio = 0.83), and 50% ESS reduction (P = .038; odds ratio: 0.84) following implant insertion through stepwise logistic regression analysis. CONCLUSIONS: Excess uvular length (>15 mm) is an important anatomic feature decreasing the efficacy of palatal implants in snoring, and additional measures, such as uvulectomy, should be considered simultaneously for better outcomes (level 4).

Effects of soft palate implants on acoustic characteristics of voice and articulation.

OBJECTIVE: To evaluate the effects of soft palate implants on voice and articulation. STUDY DESIGN: Prospective case series. METHODS: Male subjects (n=23) diagnosed with mild obstructive sleep apnea and/or habitual snoring underwent acoustic analysis with the Multidimensional Voice Program (Kay Multi-Speech Model 3700 Advanced Version; Kay Elemetrics [KayPentax], Lincoln Park, NJ) before and 8 weeks after insertion of palatal implants to determine the effects of soft palate implants on voice and articulation. Sustained vowels (/a/e/u/o/i/) and phonetically balanced carrier sentences were used for acoustic analyses. Parameters measured were fundamental frequency (F0), jitter, shimmer, noise-to-harmonics ratio, Voice Turbulence Index, Soft Phonation Index, degree of voiceless, degree of voice breaks and peak amplitude variation, first formant (F1) and second formant (F2) frequencies, and voice onset time (VOT). F1 and F2 for each vowel were determined using linear predictive analysis on a spectrogram. VOT was measured for the palatal consonant /k/ and the dental consonant /t/ on a wideband spectrogram from a carrier sentence segment that contained a syllable with a stop consonant. RESULTS: No statistically significant difference was detected in F0, F1, F2, or other MDVP parameters before and after implantation. Average VOT values measured for /t/ were not significantly different. On the other hand, average VOT values of /k/ were found to be significantly shorter. CONCLUSIONS: Implant insertion had no significant effect on MDVP parameters, F0, F1, or F2. On the other hand, articulation as a function of velar region seemed to be affected because VOT values of velar /k/ were changed.

Transcervical tongue base reduction with hyoepiglottoplasty: long-term results.

Aims To evaluate the long term results of tongue base reduction with hyoepiglottoplasty as a surgical option in the treatment of severe obstructive sleep apnea. Material and Method Severe obstructive sleep apnea patients diagnosed as upper airway narrowing at the tongue base level were treated with transcervical tongue base reduction with hyoepiglottoplasty. Seven years after single stage multilevel surgery, the patients were reevaluated clinically, radiologically and polysomnographic records were taken. Preoperative, early postoperative and long-term postoperative parameters were compared to determine the success rate of the surgical technique. Results In the postoperative long-term follow-up Epworth sleepiness scale (ESS) scores were reduced to 4 and 6 respectively 2 months after surgery despite the initial values of 17 and 15. BMI were decreased from 29.7 and 27.9 kg/m(2) respectively to 26 and 24 kg/m(2). The apnea/hypopnea index (AHI) were reduced to 14.1 and 16.2 respectively from 68.6 and 83.83. O(2) nadir was 55 and 66% respectively and improved to 86 and 89%. Flexible nasopharyngoscopy revealed competent airway in both retropalatal and retroglossal level. Bed partners scored snoring as 2/10 and 4/10 corresponding to very mild and moderate. Daytime somnolence and witnessed apneic periods were completely disappeared in both patients. Conclusion Open tongue base resection with hyoepiglottoplasty is effective among all other surgical corrections of sleep apnea even after 7 years postoperatively.

The comparison of cephalometric characteristics in nonobese obstructive sleep apnea subjects and primary snorers cephalometric measures in nonobese OSA and primary snorers.

The objective of the study is to evaluate the cephalometric characteristics and investigate the measurement differences between habitual snorers and subjects with obstructive sleep apnea (OSA) in nonobese Turkish male population. The study design is prospective and nonrandomized. The setting is sleep-snoring center of referral hospital. Total of 60 male subjects constituted OSA (n = 20), habitual snorer (n = 20) and control group (n = 20). Clinical evaluation, Epworth sleepiness scale scoring, flexible nasopharyngoscopy, polysomnography, Tweed and Delaire analysis on cephalometric images were performed. The main outcome measures include cranial base maxillary angle (SNA), cranial base mandibular angle (SNB), posterior airway space (PAS), mandibular plane and hyoid distance (MPH), soft palate length, soft palate thickness, cranial height ratio (C2/C1), cranial base angle (C1⊥C3), and craniofacial angle (C3⊥F1) parameters were compared. In comparison of OSA and habitual snorers, PAS at palatal and tongue base level (p = 0.037, p = 0.001), MPH (p = 0.07), C3⊥F1 (p = 0.001) were found statistically different. In comparison of controls with OSA and habitual snorers PAS at palatal level (p < 0.001, p = 0.01), MPH (p < 0.001, p = 0.015), soft plate length (p < 0.001, p < 0.001) and thickness (p < 0.001, p = 0.056) were found statistically different. The soft palate length, PAS, C3⊥F1 and MPH were detected as the most effective four parameters in discriminating three groups. In conclusion, this study increased MPH, soft palate length and decreased PAS were identified as the determinant characteristics in OSA and habitual snoring group. PAS and MPH values reported were higher in OSA as compared to habitual snorers. The selected cephalometric data may be used as a complementary to endoscopic examination, sleep tests and imaging techniques to determine anatomic site, management plan and follow-up of outcome in habitual snorers and OSA subjects.

Laser reduction glottoplasty for managing androphonia after failed cricothyroid approximation surgery.

OBJECTIVE: To treat androphonic voice quality after failed cricothyroid approximation (CTA) surgery. STUDY DESIGN: Prospective case series. METHODS: The voices of three male-to-female transsexuals, two constitutional androphonic females, and one patient with ambiguous genitalia assigned to the female phenotype were deemed to be unimproved after CTA. The patients underwent laser reduction glottoplasty (LRG) surgery tailored to each case between 2001 and 2005. Vocal outcomes were evaluated according to fundamental frequency (FF), satisfaction status, voice-related quality of life (V-RQOL) measures, and ratings of recorded voices by 10 blinded listeners after 12 months postoperatively. RESULTS: The LRG provided an additional mean gain of 45.17±8.47Hz (mean±standard deviation) in the FF, equal to 4.36±0.84 semitones. The mean FF increased significantly (P<0.05) from 158.33±12.14Hz preoperatively to 203.50±13.34Hz postoperatively. All patients reported satisfactory female quality in their voices and greetings with female salutations in nonvisual communications. Their voice-related quality of life (V-RQOL) measures were high and significantly elevated (P<0.05) after LRG. The masculine voice-quality ratings significantly shifted to feminine in the listeners' assessment. No major complications were observed during follow-up, with the exception of mild vocal fold edema that disappeared by 8 weeks postoperatively. CONCLUSIONS: LRG can be used in androphonic cases that fail to obtain a high-pitched feminine voice after CTA.