Comparison of contact endoscopy and frozen section histopathology in the intra-operative diagnosis of laryngeal pathology.

Andrea et al. were the first to use contact endoscopy in the diagnosis of laryngeal disease, in 1995. This method enables in vivo microscopy of laryngeal mucosa. In the present study, comparison of contact endoscopy with frozen section histopathology was performed in 142 patients with various diseases of the larynx. Paraffin section histopathology diagnosed 70 benign lesions, 23 precancerous lesions and 49 malignant lesions. Frozen section histopathology showed a sensitivity of 89.8 per cent, a specificity of 98.9 per cent and an accuracy of 95.7 per cent (chi2 = 1.5; p = 0.18). Frozen histopathology diagnosed 45 malignant lesions, including one false positive and five false negative results. Contact endoscopy yielded a sensitivity of 79.59 per cent, a specificity of 100 per cent and an accuracy of 92.95 per cent (chi2 = 8.1; p = 0.002). All malignant lesions diagnosed by contact endoscopy were confirmed by histopathology; contact endoscopy failed to recognise malignant lesions in 10 patients. Contact endoscopy is preferable to frozen section histopathology as it is noninvasive, provides information on microscopic diagnosis and laryngeal lesion margins, and enables visualisation of the laryngeal mucosa microvasculature. The use of contact endoscopy along with frozen section histopathology improves diagnostic accuracy and allows for operative (or other) therapy to continue according to the results obtained.

Unusual stab wound of the temporal region.

We report the case of an unusual penetrating injury of the temporal region of the head caused by knife. A long kitchen knife was protruding from the upper auricular area of the left temporal region of victims head. It cut through the posterosuperior part of the left auricula and remained fixed to the postauricular region. Brain computorized tomography (CT) scan revealed that the knife had reached deep into the petrous part of the temporal bone, and was directed toward the sulcus of the sigmoid sinus. There were no signs of intracranial bleeding. An otorhinolaryngologist and a neurosurgeon removed the knife in operating room, with the patient in general anesthesia. The audiogram obtained after 7 days of hospitalization showed left conductive hearing loss of 40 dB at frequencies up to 2 kHz, and of 90 dB above 2 kHz, probably due to hemotympanum caused by the operation. Control examinations performed 14 days and one month after discharge confirmed the patients complete recovery and no significant defects in his hearing or balance. We suggest multidisciplinary teamwork as a proper approach in the treatment of such injuries.

High bifurcation of common carotid artery, anomalous origin of ascending pharyngeal artery and anomalous branching pattern of external carotid artery.

We present a rare case of combined high bifurcation of the common carotid artery, anomalous origin of the ascending pharyngeal artery and unusual branching pattern of the external carotid artery. The right common carotid artery bifurcated at the level between the second and the third cervical vertebrae, giving rise to the ascending pharyngeal artery just below the bifurcation. The right external carotid artery branched directly at its origin into the superior thyroid, lingual and occipital arteries and the distal part of the external carotid artery. The latter gave rise to the right facial artery and finally bifurcated into the maxillary and superficial temporal arteries. The right posterior auricular artery arose from the right occipital artery. The finding was unilateral and other vascular anomalies were not observed. The embryogenesis of such a combination of anomalies is not clear, but the anatomic consequences may have important clinical implications.

Ear injuries caused by lightning: report of 18 cases.

The clinical management and long-term outcome in lightning survivors with substantial ear damage treated at the Department of Otorhinolaryngology, University Hospital Split during the 1984-1999 period are reviewed. Results of clinical management and outcomes of lightning ear damage in 18 patients (mean age 35.3 +/- 5 years) were retrospectively analyzed. On admission, all patients complained of severe pain, tinnitus and hearing impairment. Otomicroscopy revealed tympanic membrane rupture in 12 patients. The active therapeutic approach included immediate otomicroscopy, aseptic aspiration toilet, and eversion of perforation edges. In all patients, the ruptures healed well, and restitution of the hearing function was achieved. Follow-up examination performed in 1999 (13.2 +/- 2.9 years later) in 11 patients (mean age 52.3 +/- 6.1 years) revealed an almost identical audiogram as on discharge from the hospital, however, neuropsychological testing revealed numerous sequelae. Tympanic injury caused by lightning should be actively treated. Lightning survivors require additional psychotherapeutic treatment.

Primary echinococcosis of the sternocleidomastoid muscle.

Muscular echinococcosis accounts for 0.5% to 5.4% of all hydatid disease cases, with very little data on the incidence of muscular echinococcosis of the head and neck. We report a unique case of primary echinococcosis of the right sternocleidomastoid muscle in a 56-year-old man. Preoperative assessment by ultrasound and fine needle aspiration did not point to echinococcosis. We suspected the right diagnosis intraoperatively and confirmed it postoperatively by pathohistology and serologic tests. Echinococcosis of the liver and the lungs was also excluded postoperatively. Combination of operative treatment and postoperative albendazole herapy in two 28-day cycles one month apart resulted in complete regression of the disease. Echinococcosis should be considered as differential diagnosis of a multicystic mass in neck, particularly if it is of longstanding duration. Serologic tests for echinococcosis should be included in differential diagnostic procedures for each multicystic formation on the neck, especially in endemic areas.

[Effect of the menstrual cycle and ondansetron on postoperative nausea and vomiting]. / Utjecaj menstrualnog ciklusa i ondansetrona na poslijeoperacijsku mucninu i povracanje.

The incidence of postoperative nausea and vomiting (PONV) has been studied in a prospective group of 92 female patients in the generative period, undergoing thyroid surgery. In a subgroup of 47 examinees we analyzed PONV incidence according to the surgery time within the frame of their menstrual cycle. The highest number was observed in periovulatory and premenstrual periods (p < 0.02). In the formal trial, 24 patients that randomly received ondansetron (8 mg in 4 mL i.v.) and significantly less PONV than their 21 placebo controls (4 mL saline i.v.): 4 or 16.8% vs. 11 or 53.6% (p < 0.04).

[Aspiration of foreign bodies in the bronchi in children]. / Aspiracija stranog tijela bronha u djece.

Records on 28 children (19 boys and 9 girls), mean age 3.1 years (range 6 months to 11 years), treated for foreign body aspiration (FBA) at the Department of Pediatrics, Split Clinical Hospital, during the 1992-1997 period, were analyzed. The mean hospital stay was 12.3 days (range 1 h to 92 days). History data on tracheobronchial FBA were available in 23 (82%) children. Radiologic findings pointed to FBA in 22 (77%) children. Rigid tracheobronchoscopy was performed in all patients, and proved successful in 26 (93%) of children. Digestible foreign bodies and food particles were removed in 22 (78%) children. Right-sided and left-sided bronchial FBA was recorded in 14 (50%) and 13 (46%) patients, respectively, whereas bilateral obstruction was present in one patient. The importance of suspected FBA in children with pronounced symptoms of coughing, dyspnea and choke is emphasized. Rigid tracheobronchoscopy and foreign body removal by forceps under anesthesia is an efficient and safe method, and we recommend its wider use in clinical practice.

Histopathologic variants of basal cell carcinoma correlation with sex, age and localization.

During the 6-year period (January 1, 1993 to December 31, 1998) in the Laboratory for Dermatopathology of Department of Dermatovenereology in Clinical Hospital Split, 1616 basal cell carcinomas (BCC) of a total of 323 investigated specimens were diagnosed. The incident rate varies from 92 to 114 BCC per 100,000 inhabitants in the Split region. The sex ratio in material is 1.2:1 in favor of males. The frequence of BCC increases with the advanced age in both sexes with the peak in the age group from 70 to 79 years. The most frequent location in both sexes is the nose followed by cheeks and trunk. Statistic analysis showed a significantly higher occurrence of BCC in temporal region in the males and perioral region in the females; respectively. The solid variant is the most frequent followed by superficial multicentric and solid-adenoid. Pure variants are found in 83.1% specimens, and mixed variants in 16.9%. Solid and adenoid variants are the most frequent on the nose and cheeks. According to statistics cystic variant is significantly higher on the forehead, and morpheic variant on the nose. Superficial multicentric variant is statistically more frequent on the trunk than on other locations. All specimens were reexamined and histopathologic variants were obtained. Over 2000 data are comprised which is a sufficient examination sample. In programs such as SPSS, and Graph master ver 1.12, Win95, MO'97 (Word, Excel, Access) on Pentium II 200 MHz, floppy, 64 MB RAM, HDD 2.1 GB, CD x24, HP LJet 6L, a comprehensive analysis has been performed.

Giant rhinophyma--a case report.

Rhinophyma is an uncommon condition that often results in both functional and cosmetic impairment. A 65-year old male with a huge rhinophyma, that had extremely grown in the last three years, is presented. The huge tumor was removed under local anaesthesia with electrosurgical knife preserving the alar cartilage. Both, the immediate and late result were satisfactory. The relevant literature is discussed.

Disturbances in plasma sodium in patients with war head injuries.

Polyuria with marked plasma sodium disturbance was present in 39 of 224 patients with isolated craniocerebral war injuries. Twenty-one of these 39 patients had hyponatremia (sodium level < 130 mmol/l) and polyuria. Eight of them (38%) died within 30 days after trauma. The remaining 18 patients developed classic diabetes insipidus syndrome, and 6 of them (33%) died of hypernatremia within 30 days after trauma. The mortality in both patients with hyponatremia and patients with diabetes insipidus was higher in those with greater disturbances of plasma sodium concentration with polyuria and those with lower Glasgow Coma Scale scores.

The impact of the menstrual cycle and ondansetron on postoperative nausea and vomiting.

The incidence of postoperative nausea and vomiting was studied in a prospective group of 94 women of child-bearing age (18-42 years), undergoing unilateral elective thyroid surgery. In a subgroup of 47 examinees the postoperative nausea and vomiting episodes were analyzed according to the time of surgery within their menstrual cycle: the highest occurrence was observed in the periovulatory and premenstrual periods (65.5% vs. 27.8%, p < 0.02). In the formal part of this study, 25 patients randomly received ondansetron (8 mg intravenous [i.v.]): they had significantly less postoperative nausea and vomiting than their 22 placebo controls (4 ml saline i.v.): 16.0% vs. 45.5% (p < 0.04). It is concluded that elective surgery in young and middle-aged female patients is best avoided premenstrually and in the middle of their cycle. In these very periods, however, ondansetron effectively reduces the incidence and intensity of postoperative nausea and vomiting by about 70%.

Septic syndrome and septic shock in the wounded treated at the Split Clinical Hospital Intensive Care Unit.

INTRODUCTION: A retrospective study on the occurrence of septic syndrome and septic shock, as well as multiorgan failure, in the wounded at the Split Clinical Hospital Intensive Care Unit (ICU). PATIENTS AND METHODS: From 1991 to 1995, 257 wounded persons were treated at the Split Clinical Hospital ICU. Criteria for septic syndrome included evident infection, body temperature > 38 degrees C or < 30.5 degrees C, leukocytosis or leukopenia, thrombocytopenia, as well as dysfunction of one organ. The criterion for septic shock was septic syndrome with hypotonia. RESULTS: Fifteen patients with septic syndrome and 9 patients with septic shock were admitted and treated at the ICU. Septic syndrome developed in 17 patients and septic shock in 16 patients at the ICU. Acute respiratory distress syndrome developed in 16, renal insufficiency in 26, gastrointestinal disorders in 6, hepatic disorders in 4, hematologic disorders in 13, and central nervous system dysfunction in 17 patients. Twenty-eight percent of patients died in septic syndrome, and 74% died in septic shock. CONCLUSION: Septic syndrome and septic shock were the most common causes of death in wounded persons treated at Split Clinical Hospital ICU. At the earliest phase the main cause of death was refractory hypotension, and at the later stage the main cause of death was multiorgan failure.

Titrated total intravenous anaesthesia (TIVA) in war.

In the Rama mobile war hospital, intravenous (i.v.) anaesthesia was used in 78 patients undergoing surgical procedures lasting 4-25 min. Boluses of thiopentone (Group 1), propofol (Group 2), propofol + alfentanyl (Group 3), and ketamine + midazolam (Group 4) were used. Induction of anaesthesia, resulted in a mean blood pressure decreased about 15%. Apnoea of more than 20 sec was observed in Group 3, but no naloxone was required. Recovery was rapid enabling patients to maintain their own airway. The use therefore of titrated anaesthetics in war is considered acceptable.

[Pulmonary edema following obstruction of the upper airway]. / Plucni edem nakon opstrukcije gornjeg disnog puta.

The development of pulmonary edema after the relief of upper airway obstruction in two patients is described. Pulmonary edema in those patients was the result of increased negative intrapleural and intra-alveolar pressure during forceful inspiration and in the course of upper airway obstruction. An increase in the venous return occurs and the established transpulmonary pressure gradient promotes transudation into the interstitium and alveoli. Consequent alveolar hyperventilation results in hypoxia and acidosis. All patients developing pulmonary edema should be treated with positive pressure ventilation within 24-36 hours. The aim of this study was to alert physicians that besides know factors for the development of cardiogenic and noncardiogenic pulmonary edema there are also other significant mechanisms that cause the accumulation of fluid in pulmonary tissue.