Vocal fold masses removal--the sub epithelial micro flap technique.

Vocal fold mass removal techniques were significantly modified back in 1970s by Hirano's laminar vocal structure and physiology of phonation works, as well as Titze's vibratory vocal cycle works. New methods were to come. Removing the lession by maximum preservation of vocal laminar microstructure (lamina propria and epithelium) and minimal damage of surrounding normal vocal tissue, was pointed out. Microflap technique is based on presenting the superficial layer of lamina propria with the lesion and removing the lession without damage of the mucosa. Preserving of the mucosal layer provides the shield for vibratory substructures. There are two elementary approaches for microflap: lateral and medial. Lateral microflap technique enables better identification of vocal ligament and lowers the risk of it's injury, particulary when scars and tightly adherent lessions are present. This technique has been used in case of big or diffuse lesions, such as vocal oedema or vocal lygament identification difficulties (e.g. vocal scarification). Medial microflap technique seems to be appropriate in removing smaller, localised lessions, such as cysts and vocal polyps. Our 45 patients experience is presented in this article, in 30 patients lessions were removed by lateral microflap technique (46 vocal cords in total), while 15 patients were treated by medial microflap technique. The outcome was assumed by endovideolaryngostroboscopic analysis of glottal occlussion and mucosal wave prior and following to the procedure. Reinke oedema management results were analysed separately.

Conservative treatment vs phonosurgery.

In Phoniatric Dpt. everyday practice we try to keep specific multidisciplinary approach to the communication disorders, that includes an expert team using modern technology. Over the last six years we have treated 110 singers (3% of all new cases) and the results of their diagnostic and therapeutic management are presented here. There were 67 women and 43 men, 41 were smokers and 69 nonsmokers. The singing genres included 24 pop, 41 folk, 8 ethnic, 29 choral and 8 opera singers. The therapy success was compared with the demographic parameters, level of education and music genres across the subjects. A precise history, clinical examination, endovideolaryngostroboscopy and multidimensional computer analysis of voice and speech was carried out by two phoniatricians, two logopeds, two nurses and one clinical psychologist. Additional consultations were carried out by audiologists, allergists, endocrinologists, chest physicians, gastroenterologists and neurologists where necessary. We suggest that the gold standard is conservative therapy, with phonosurgery if conservative measures fail. We also suggest that an annual systematic examination is optimal in preventing disease in professional singers.

Overlooked nasal foreign body with a 48-year latent period.

Foreign bodies of the nose are relatively frequent in pediatric population, while in the adults, they are usually seen in disturbed persons. Overlooked nasal foreign bodies may be singled out as a special entity. They become rhinolites over time with latent period of several decades. Our paper illustrates an overlooked foreign body in the nose--i.e. encrusted plastic bead which, after the asymptomatic period of 48 years, induced the unilateral mucopurulent and ichorous secretion from the nose. Rhinolite should be suspected if radiological diagnostics detected calcified mass in the nose together with unilateral nasal symptomatology. Surgical removal of rhinolite results in complete management of such problem. This case indicates the significance of medical history data and examination of nasal cavity in any adult patient with unilateral nasal symptomatology which is refractory to conservative treatment. Computerized tomography of paranasal sinuses is an important adjunct diagnostic tool in indefinite cases. Nevertheless, it often happens that only the extraction of rhinolite indicates the diagnosis that is not usually suspected in adult persons.

[The role of functional sinus surgery for treatment of antrochoanal polyp].

UNLABELLED: Antrochoanal polyp (ACP) is a benign lesion which arises from the mucosa of maxillary sinus, fills it and expands through natural ostium towards choana protruding in the epipharynx. OBJECTIVE: to present our experience in endoscopic surgery of ACP. MATERIAL AND METHODS: prospective study included 24 patients operated at the Institute of Otorinolaryngology and Maxillofacial surgery, Clinical Center of Serbia, Belgrade, in the period 2002-2004. Subjective symptoms, endoscopic and CT findings were evaluated postoperatively, following up the patients in the period 12-20 months. Subjective difficulties of patients were tested by 100mm-analogue scale, while endoscopic and CT findings were demonstrated by three-stage scale from 0 to 2. Applying the technique of ACP extraction in Trendelenburg's position and approaching the part which protrudes in the epipharynx, we successfully removed the endonasal part by means of curved forceps for epipharyngeal biopsy. By endoscopic middle meatotomy, the natural ostium of maxillary sinus was expanded and pathological process from the very sinus was successfully removed. RESULTS: only one female patient had the majority of symptoms after the operation, while all others had no complaints. Endoscopic and CT findings were normal in all patients at the latest control, without any signs of ACP recurrence. There were no intraoperative or postoperative complications. CONCLUSION: minimal damage to sinus mucosa due to forceps is lesser problem than complications developed upon creating even the miniature opening in the canine fossa. Using this technique, a dexterous surgeon may successfully extract patho-logical process with minimal incidence of recurrence, and, more important, with no complications and maximally fast recovery of patients.

[Dilemmas and controversies related to cancers of the anterior laryngeal commissure]. / Dileme i kontroverze karcinoma prednje komisure larinksa.

From diagnostic and therapeutical aspect, the cancers of the anterior laryngeal commissure are the separate category in glottic cancers. But, they have not been individually classified in the majority of statistical reports, and, therefore, the incidence of the anterior commissural cancer should be taken with precaution. The issue of therapeutical strategy is controversial, considering the options and limitations of resections of the anterior commissural tumors, within the conception of oncological radicalism. Dilemmas are being especially faced with in radiotherapy, given the failures and unsatisfactory radiotherapeutical results. The prospective clinical study included the analysis of the incidence of primary and secondary cancers of the anterior commissure of the larynx. The follow-up of five-year survivals allowed for the establishment of efficiency of the applied therapeutical methods. The results of five-year survival in patients treated by primary surgery were highly more significant in relation to results obtained by radiotherapy of patients.

[Onco-surgical significance of anatomo-morphological specificity of glottic region of the larynx]. / Onkohirurski znacaj anatomo-morfoloskih specificnosti glotisne regije larinksa.

Glottis is a medium level of the larynx, involving the vocal cords, vocal process of arytenoid cartilage, and the anterior and posterior commissures. This region of heterogeneous histomorphological structure has specific characteristics: the internal striated muscles, the outer and inner perichondrium, atypical intra-cartilaginous areas of ossification, and unusual muscular insertion to cartilage. Microtomy of 3 thick successive sections was performed at the level of the upper surface of vocal cords. Standard histological staining methods were used. Microphotographs were taken by light microscope under different magnification along with histomorphometric measurements. Cancer spread is partially restricted by anatomic barriers: vocal ligament and tendon of the anterior commissure, and subsequently by the elastic cone. Easier tumor extension may be due to absence of the internal perichondrium and ossification of thyroid cartilage. Microvascularization of the anterior commissure is significant for tumor spread in glottis and paraglottic space. The role of commissural lymph network in local spread of the cancer is completely vague. It is certain that there are causes, still unrecognized, which have an effect on the pathways and direction of malignant tumor spread.

[Effect of the extents of surgical resection in total laryngectomy on esophageal voice and speech rehabilitation]. / Uticaj obima hirurske resekcije kod totalne laringektomije na uspostavljanje ezofagusnog glasa i govora.

The study of functional results of total laryngectomy cannot be separated from articulation of esophageal voice and speech. To achieve success of phoniatric rehabilitation in laringectomized patients, it is necessary to be well aware of pathological sequelae of the very operation, long-term adverse effect of oncological risk factors as well as postoperative anatomo-physiological changes. Anatomic results of total laryngectomy depend on the type of surgical intervention and probable radiotherapy. The extent of surgical procedure, primary dictated by oncological indications, has the essential effect to articulation of esophageal voice and speech. If possible for oncological reasons, hyoid bone should be particularly left intact. Extensive surgical interventions of hypopharynx and the base of the tongue during laryngectomy, neck dissection--especially the radical one, and subsequent radiotherapy, all of them significantly reduce the possibility to produce esophageal voice and speech. Total laryngectomy eliminates the creator of voice and vibrations, which are acoustically perceived as esophageal voice, proceeding at the level of pharyngoesophageal junction. For this reason, the quality of newly created vibrating narrowing is especially important.

[The analysis of the quality of life in laryngectomized patients]. / Analiza kvaliteta zivota laringektomisanih bolesnika.

Total laryngectomy, as extremely mutilating surgical intervention, results in drastic changes of the style and quality of life. The trauma of laryngectomy is huge, both to patients and their environment. The most pronounced changes of the quality of life of laryngectomized patients are seen at marital, familial, professional, business and communication aspects. Malignant disease and total laryngectomy significantly reduce working capacity, producing, besides professional, the economical difficulties. Psychological implications associated with total laryngectomy are the most severe, comprehensive ones and require multidisciplinary approach. The study analyzes the frequency and distribution of factors affecting the quality of life of laryngectomized patients (sex, age, psychic status, probable history of chronic diseases, impairment of hearing and social-family environment of patients). Significant improvement of the quality of life of laryngectomized patients is achieved by systemic, planned and multidisciplinary rehabilitation of patients as well as their immediate environment. The need for the association of laryngectomized patients is stressed.

[Clinical study of undifferentiated carcinoma of the nasopharynx (UNCT) in patients with cervical node type of disease]. / Klinicka studija UCNT bolesnika sa cervikalnim nodalnim tipom bolesti.

Indifferentiated carcinoma of the nasopharyngs is clinicaly-histological-imunologic entity which is often diagnosed in our country. There are three clinical types, but nodal cervical type of disease is the most interesting type for surgeons while the combined type is more interesting for otolaiyngologist. Among seventy-seven patients diagnosed with undifferentiated carcinoma of the nasopharyngs with nodal cervical type of disease, on the Institute of Otolaryngology and Maxillofacial Surgery Clinical Centre of Serbia during the period between 1993-1997 there were N0-21%, N1-49%, N2-18% i N3-12%, no mater of the T category. The disease more often occurs between male population (2:1), mostly between age 41-60. The rate for five year period of surviving for two different chemioterapeutical protocols is as follows: for categories N0 and N1-20% for mono Zorubicin and 61% for the same category for Z-CDDP. The same rate for categories N2 and N3 is 11% for mono Zorubicin and 33% for the same category for Z-CDDP. Much better rate of survival in comparison with previous decades is achieved due to better diagnosing on time in which are sistematicaly ineluded epypharyngoscopy in general anestesia with biopsy, CT and NMR and EBV serology.

[Classification of chronic inflammation of the upper respiratory tract based on allergy status]. / Klasifikacija hronicnih inflamacija gornjih disajnih puteva na bazi alergijskog statusa.

Almost one third to one half of all patients in otorhinolaryngologic practice experience some kind of inflammation of the upper respiratory tract out of which allergic mechanisms, either as primary factors or secondary ones, appear in 30-40% of adults and 60-80% of children and adolescents. The objective of this study was to analyse inflammatory conditions of the upper airways on the basis of allergic state of the patient and to establish the classification that will respect the actual immunological alteration level (subclinical allergy, clinical allergy) and spreading (localized allergy, generalized allergy). Inclusion criteria for all sixty nine patients were the diagnosis of chronic upper airway inflammation and their exposition just to ubiquitous allergens. Diagnostic procedure included anamnesis, physical examination and allergic in vivo testing of the skin and nasal mucosa to inhalant allergens. The certain categories of results were established for the skin prick-test (positive, negative, indefinite), specific nasal provocation test (positive, negative, hyperreactive) and nasal symptoms (present, absent). By using a strictly determined combination of results, we were able to define the six groups in our classification: nasal clinical allergy (30% of patients), non-nasal clinical allergy (19% of patients), localized nasal allergy (11% of patients), latent allergy (3% of patient), nonspecific nasal hyperreactivity (12% of patient) and non-allergic inflammation (25% of patients). Our classification takes into consideration the modern knowledge in the field of allergology and may bring an additional quality in respect to selection of therapy options, long-term follow-up of allergy status evolution in the individual person as well as intragroup and intergroup analysis of parameters important to evaluate the effects of antiallergic prevention or therapy.

[Clinical study of routes of onset of inflammatory diseases in the maxillary sinuses]. / Klinicka studija puteva nastanka zapaljenjskih oboljenja maksilamih sinusa.

Pathways of the maxillary sinus diseases is an interesting issue investigated by many authors during the past decades. The goal of this research was to study the pathways of infection spreading into the maxillary sinuses and to compare them in relation to their frequency, underlying causes and general epidemiologic characteristics of the involved population. A total number of 150 adult patients of both gender suffering different diseases of maxillary sinuses were included into the study. Pathways rising maxillary sinuses diseases were diagnosed on the basis of standard clinical procedures including CT scean and MRI of the region. We found inflammatory processes to dominate the tumorous ones (107:43 patients). Rhinogenic type of sinusitis was the most frequent disease (72 patients) while odontogenic sinusitis (35 patients) was significantly less frequent. No case of traumatic or hematogenic maxillary sinusitis was found. Rhinogenic maxillary sinusitis is characterised by spontaneous onset while odontogenic one is mostly of arteficial origin after surgical procedures in the oral cavity (88% of patients). In contrast to rhinogenic type, odontogenic maxillary sinusitis is far more frequent in younger patients.

[Vasomotor skin tests in non-eosinophilic and eosinophilic long-term (perennial) nonallergic rhinitis]. / Vazomotorni kozni testovi u neeosinofilnom i eozinofilnom dugotrajnom ("perenijalnom") nealergijskom rinitisu.

INTRODUCTION: It has generally been assumed that "perennial" non-allergic rhinitis is a heterogeneous syndrome consisting of at least two groups: non-eosinopilic and eosinophilic. Opposite to non-eosinophilic group, eosinophilic group is characterized by nasal secretion eosinophilia, frequent evolution to nasal polyposis or complete ASA triad (nasal polyposis, intrinsic asthma and intolerance of non-steroidal anti-inflammatory drugs) and by a good response to treatment with anti-histamines and corticosteroids. These characteristics obviously separate eosinophilic from non-eosinophilic rhinitis and point out the importance of nasal secretion eosinophilia for the evolution and therapy of rhinitis. However, the distinction between eosinophilic and non-eosinophilic rhinitis can only be made by nasal cytology. Skin tests with vasomotor agents were carried out to characterize vasomotor skin reactivity in "perennial" non-allergic rhinitis and determine whether the patients with non-eosinophilic rhinitis differ from patients with eosinophilic rhinitis. METHODS: On the basis of the examination of nasal smears of eosinophils, 74 patients with "perennial" non-allergic rhinitis were divided into non-eosinophilic (n = 63) and eosinophilic group (n = 11). Nasal eosinophilic was considered significant when 20% and more of the cells in nasal smear were eosinophils. Skin reactivity to intracutaneous test with different concentrations of papaverine, metacholine, histamine and compound 48/48 was measured, as well as specific skin reactivity to control saline solution. Pathological skin reactivity to vasomotor agents was defined as hyporeactivity to papaverine (5 mg/mL), when wheal-and-flare skin reaction diameter was less than 15 mm; hyper-reactivity to metacholine (0.02, 0.2 and 2.0 mg/mL), when two of three wheal-and-flare skin reaction diameters were greater than 15, 25 and 31 mm, respectively; hyper-reactivity to histamine (0.01, 0.1, 1.0 and 10.0 micrograms/mL), when three of four wheal-and-flare skin reaction diameters were greater than 7, 13, 25 and 40 mm, respectively; and hyper-reactivity to compound 48/80 (0.01, 0.1, 1.0 and 10.0 micrograms/mL, when three of four wheal-and-flare skin reaction diameters were greater than 9, 16, 26 and 38 mm, respectively. RESULTS: Seventy four patients with "perennial" non-allergic rhinitis were included in the study. There were 51 females, age range from 18 to 57 yrs. (mean 37 yrs.) and 23 males, age range from 18 to 73 yrs. (mean 44 yrs.). The difference between the number of females and males was significant (p = 1.1 x 10(-3)), while no significant difference regarding the age between females and males was found (p = 0.122). Significant percentage of eosinophils was found in 15% of "perennial" non-allergic rhinitis patients, and they were classified into eosinophilic group (n = 11). In this group, the percentage of eosinophils varied from 20% to 80%, mean 35%. In non-eosinophilic group (n = 63), it ranged from 0% to 10%, mean 1%. No significant difference concerning sex and age between the two groups of the rhinitis patients was observed (Table 1). There was no significant intergroup difference for pathological skin reactivity to papaverine, metacholine, histamine, compound 48/80 and saline (Table 2). Total pathological skin reactivity to vasomotor agents, single and in combination, was found in 78% of non-eosinophilic and in 91% of eosiniophilic rhinitis patients (Table 3). In both, non-eosinophilic and eosinophilic groups, frequencies of total pathological skin reactivity to vasomotor agents was significantly greater than frequencies of total normal skin reactivity (p = 1.1 x 10(-5) and p = 0.007 respectively). However, the difference of total pathological skin reactivity to vasomotor agents between the two groups was not significant (p = 0.552). (ABSTRACT TRUNCATED)

[Intradermal tests using vasomotor agents in allergic rhinitis]. / Intradermisni testovi vazomotornim agensima u alergijskom rinitisu.

INTRODUCTION: Allergic rhinitis is characterised by nasal hyperactivity to specific and non-specific agents. For research purposes, non-specific nasal hyperactivity can be estimated by histamine and metacholine nasal challenge tests. At present, nasal challenge tests are not used for routine diagnosis of rhinitis. Wayoff and colleagues proposed the examination of the skin reactivity to papaverine, acetylcholine, histamine and compound 48/80 in rhinitis patients. Our previous study of skin reactivity to vasomotor agents, using modified skin tests of Wayoff and colleagues showed their clinical validation and usefulness for subclassification of patients with non-allergic rhinitis. To the present, there are only a few studies of skin reactivity to vasomotor agents in patients with allergic rhinitis. The aim of this study was to examine the skin reactivity to vasomotor agents of allergic rhinitis patients and determine whether the patients with allergic rhinitis differ from healthy subjects. METHODS: A prospective, controlled, in vivo study was carried out in 86 subjects: 44 patients with allergic rhinitis and 42 healthy subjects. Skin reactivity was examined by intradermal tests with different concentrations of papaverine, metacholine, histamine and compound 48/48. The non-specific skin reactivity to saline was also measured. Skin reactivity to intradermal test with different concentrations of papaverine, metacholine, histamine and compound 48/48 was measured, as well as specific skin reactivity to control saline solution. Pathological skin reactivity to vasomotor agents was defined as follows: hyporeactivity to papaverine (5 mg/mL), when wheal-and-flare skin reaction diameter was less than 15 mm; hyper-reactivity to metacholine (0.02, 0.2 and 2.0 mg/mL), when two of three wheal-and-flare skin reaction diameters were greater than 15, 25 and 31 mm, respectively; hyper-reactivity to histamine (0.01, 0.1, 1.0 and 10.0 mg/mL), when three of four wheal-and-flare skin reaction diameters were greater than 7, 13, 25 and 40 mm, respectively; and hyper-reactivity to compound 48/80 (0.01, 0.1, 1.0 and 10.0 mg/mL), when three of four wheal-and-flare skin reaction diameters were greater than 9, 16, 26 and 38 mm, respectively. RESULTS: The study included 86 subjects: 44 patients with allergic rhinitis and 42 healthy subjects. The control group of healthy subjects consisted of 22 females, aged from 18 to 35 yrs (mean 28 yrs), and 20 males, aged from 18 to 40 yrs (mean 28 yrs). The difference between the number [p(= 0.758) > 0.05] and age [p(= 0.990) > 0.05] of females and males was not significant. In the allergic rhinitis patients group, there were 23 females, aged from 18 to 54 yrs (mean 33 yrs) and 21 males, aged from 18 to 50 yrs (mean 36 yrs). The difference between the number [p(= 0.763) > 0.05] and age [p(= 0.558) > 0.05] of females and males was not significant. Frequencies of pathological skin reactivity to single vasomotor agents and saline in the control group of healthy subjects and in the allergic rhinitis patients group are shown in Table 1. In the control group, frequencies of normal skin reactivity to papaverine [p(= 1.8 x 10(-7)) < 0.01], metacholine [p(= 4.3 x 10(-6)) < 0.01], histamine [p(= 4.3 x 10(-6)) < 0.01], compound 48/80 [p(= 1.8 x 10(-7) < 0.01] and saline [p(= 6.9 x 10(-4)) < 0.01] were significantly greater than frequencies of pathological skin reactivity. In the patients group, frequencies of normal skin reactivity to papaverine [p(= 6.0 x 10(-8)) < 0.01] and saline [p(= 2.6 x 10(-3) < 0.01] were significantly greater, and to metacholine [p(= 0.016) < 0.05] were significantly greater than frequencies of pathological skin reactivity. In this group, the difference between frequencies of pathological skin reactivity to histamine [p(= 0.366) > 0.05] and compound 48/80 [p(= 0.070) > 0.05] were not significant. There was no significant intergroup difference for pathological skin reactivity to papaverine, metacholine and saline (Table 1). In the patients group frequencies of pathological skin reactivity to histamine and compound 48/80 were significantly higher than in the control group of healthy subjects. Frequencies of pathological skin reactivity to single vasomotor agents and in combinations in the control group of healthy subjects and in the allergic rhinitis patients group are shown in Table 2. The difference of pathological skin reactivity to single vasomotor agents and in combinations between the control group (14/42) and the allergic rhinitis patients group (27/44) was significant [p(= 0.017) < 0.05]. CONCLUSION: In routine evaluation of the rhinitis patients, skin tests with vasomotor agents have some advantages: these tests do not require special equipment, they are not time-consuming, they are easy to perform and simple for the interpretation of results. (ABSTRACT TRUNCATED)