Microvascular nose reconstruction after extended tumor resection.

<b>Introduction:</b> The nose is the central and probably the most important organ of the face. In view of the three-dimensional shape and variety of tissues, reconstructive surgery after tumor resection in this anatomical region requires the surgeon's knowledge of anatomy. <br><b>Materials and Method:</b> In the years 2010-2019, 48 patients were treated in the Oncological and Reconstructive Surgery Clinic for extended nasal tumors, which required the use of free microvascular flaps after resection for functional and aesthetic supply of anatomical structures of the nose. <br><b>Results:</b> In 48 patients, a total of 92 free microvascular flaps were used for nasal reconstruction including: radial forearm free flap in 24 patients, radial forearm free flap with radial bone in 14 patients, auricular free flap in 16 patients, radial forearm free flap in combination with auricle free flap in 7 patients, double auricular free flap in 6 patients, radial forearm free flap in combination with double auricular free flap in 4 patients. Total necrosis of the free flap was noted in 4 cases, partial in 6 patients. <br><b>Conclusions:</b> The presented surgical techniques using microvascular free flaps constitute a recognized method of treatment and should be used in everyday surgeon practice. The results demonstrated in this article allow to obtain optimal functional and aesthetic effects.

Artificial neural network identifies nonsteroidal anti-inflammatory drugs exacerbated respiratory disease (N-ERD) cohort.

BACKGROUND: To date, there has been no reliable in vitro test to either diagnose or differentiate nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (N-ERD). The aim of the present study was to develop and validate an artificial neural network (ANN) for the prediction of N-ERD in patients with asthma. METHODS: This study used a prospective database of patients with N-ERD (n = 121) and aspirin-tolerant (n = 82) who underwent aspirin challenge from May 2014 to May 2018. Eighteen parameters, including clinical characteristics, inflammatory phenotypes based on sputum cells, as well as eicosanoid levels in induced sputum supernatant (ISS) and urine were extracted for the ANN. RESULTS: The validation sensitivity of ANN was 94.12% (80.32%-99.28%), specificity was 73.08% (52.21%-88.43%), and accuracy was 85.00% (77.43%-92.90%) for the prediction of N-ERD. The area under the receiver operating curve was 0.83 (0.71-0.90). CONCLUSIONS: The designed ANN model seems to have powerful prediction capabilities to provide diagnosis of N-ERD. Although it cannot replace the gold-standard aspirin challenge test, the implementation of the ANN might provide an added value for identification of patients with N-ERD. External validation in a large cohort is needed to confirm our results.

Virtual surgical planning and cone beam computed tomography in reconstruction of head and neck tumors - pilot study.

<b>Introduction:</b> The aim of the study was to prove that a combination of visual surgical planning (VSP) and cone beam computed tomography (CBCT) is an optimal technique in fibular free flap reconstructions after complex tumor resections in the head and neck region and that it leads to better functional and aesthetic outcomes. <br><b>Material and method:</b> Six patients (3 females, 3 males) with head and neck tumors were included in the study. The region concerned midface in 2 cases and mandible in 4 patients. On the basis of computed tomography of the head, fibular free flap (FFF) reconstruction was planned with the VSP technique. The 3D-printed models were prepared. At the beginning of the operation and a few minutes after the reconstruction, an xCAT CBCT by XORAN was performed. Minor corrections of the angles of the reconstructed bony parts were made where needed. The time of the operation was assessed for each case. Functional and cosmetic results were evaluated in a 1-year follow-up. <br><b>Results:</b> The mean time of operation was 6 hours and 48 minutes, which was approximately 1hour and 40 minutes less than standard reconstructive surgery. Functional recovery was achieved in all patients. Aesthetic result was unsatisfactory for 2 patients due to insufficient soft tissue masses of FFF. <br><b>Conclusions:</b> The authors claim that intraoperative CBCT imaging, regardless of the cost, improves the accuracy of aesthetic outcome of reconstructive surgeries based on VSP, especially in the region of the midface and the mandible. Further studies on a higher number of subjects are required.

Prostaglandin E2 decrease in induced sputum of hypersensitive asthmatics during oral challenge with aspirin.

BACKGROUND: A special regulatory role for prostaglandin E2 (PGE2 ) has been postulated in nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NERD). OBJECTIVE: To investigate the effect of systemic aspirin (acetylsalicylic acid) administration on airway PGE2 biosynthesis in induced sputum supernatant (ISS) among subjects with NERD or aspirin-tolerant asthma with chronic rhinosinusitis with nasal polyposis (ATA-CRSwNP), as well as healthy controls (HC). METHODS: Induced sputum (IS) was collected from patients with NERD (n = 26), ATA-CRSwNP (n = 17), and HC (n = 21) at baseline and after aspirin challenge. Sputum differential cell count and IS supernatant (ISS) levels of prostanoids, PGE2 , 8-iso-PGE2 , tetranor-PGE-M, 8-iso-PGF2 α, and leukotriene C4 , D4 , and E4 , were determined using mass spectrometry. Urinary excretion of LTE4 was measured by ELISA. RESULTS: NERD subjects had elevated sputum eosinophilic count as compared to ATA-CRSwNP and HC (median NERD 9.1%, ATA-CRSwNP 2.1%, and HC 0.4%; P < 0.01). Baseline ISS levels of PGE2 were higher in asthmatics as compared to HC at baseline (NERD vs HC P = 0.04, ATA-CRSwNP vs HC P < 0.05). Post-challenge ISS levels of PGE2 compared to baseline significantly decreased in NERD and HC (P < 0.01 and P = 0.01), but not in ATA-CRSwNP. In NERD, a similar decrease in PGE2 as in HC resulted from 2.8 times lower dose of aspirin. CONCLUSION: Aspirin-precipitated bronchoconstriction is associated with a decrease in airway PGE2 biosynthesis. These results support the mechanism of PGE2 biosynthesis inhibition as a trigger for bronchoconstriction in NERD.

First Complex Allotransplantation of Neck Organs: Larynx, Trachea, Pharynx, Esophagus, Thyroid, Parathyroid Glands, and Anterior Cervical Wall: A Case Report.

OBJECTIVE: Evaluate the possibility of performing a complex vascular allotransplant of all neck organs including skin. SUMMARY BACKGROUND DATA: There are 2 previous attempts described in the literature, none of them being that complex. The first one is nonfunctional due to chronic rejection, the second one is viable yet considerably limited in complexity (no parathyroids, no skin). METHODS: The allotransplantation was performed simultaneously on 2 adjacent operating rooms, using microsurgical techniques. RESULTS: The patient's voice, breathing through mouth, swallowing, and endocrinal functions have been fully restored. CONCLUSIONS: Achieved results show clearly that such operations performed in selected patients can nearly fully restore functional and aesthetic effects in 1 single procedure.

Face Transplant in an Advanced Neurofibromatosis Type 1 Patient.

BACKGROUND The human face is a one-of-a-kind structure with unique morphology, complexity, and function, in which different subunits are not even similar to other parts of the body. Therefore, extended complex deficits of the face are usually difficult to reconstruct, and autologous tissue restoration is generally not able to give a satisfactory aesthetic and functional outcome. The main goal of face allotransplantation is to restore symmetry, contour, and appearance as well as function of the face, especially control of orbicularis oculi and oris muscle physiology. We present the case of a total face transplant in an advanced neurofibromatosis type 1 patient - the second face transplant in Poland. CASE REPORT The recipient was a 28-year-old female with neurofibromatosis type I limited to the head region. During 24 years she underwent more than 35 surgical procedures, but for the last 3 years a significant decrease of her functionality and appearance was observed, including serious problems with speech, eating, and vision. In December 2013 she was qualified for a face transplant procedure. When the donor was found, she was matched on several clinical and biochemical characteristics including negative T and B cell cross-matching. Similarly, the transplantation procedure was done using two connected operating rooms; in the first, the donor's face was harvested, and in the second, the recipient's face was prepared - the tumor mass was resected and vascular and nervous structures were prepared. Due to the extension and complexity of the potential defect, more than 75% of head soft tissues were harvested including both auriculae, left and right eyelids, and scalp down to the occipital lower line. CONCLUSIONS Our case showed that neurofibromatosis is a real indication for a face transplantation procedure. Also, the results of rehabilitation, quality of life, motor and sensory recovery, and physiological status were comparable, showing that face transplantation based on careful selection of recipients and procedure planning is a real alternative, allowing achievement of excellent results that are far away from the outcomes of conventional reconstructions.

Characteristics, diagnosis and therapeutic strategies for IgG4-related orbital disease.

Thanks to detailed studies conducted in recent years, a new disease syndrome was identified in 2001. It is known as a IgG4-related disease and its differentiation is based on the analysis of IgG4 levels in the affected tissues. The IgG4-related disease is considered to be a generalized pathological process involving a wide spectrum of various disorders that may affect distant organs. Orbital IgG4-related disease is a recently reported issue that may prove important for the elucidation of the etiology of idiopathic, lymphoplasmacytic or fibrotic disorders of various organs, including the orbits. In this article, we are describing epidemiology and differential diagnostics of IgG4-related orbital disease with particular focus on pseudotumors, MALT lymphomas and lymphocyte/plasma cell infiltrations of the orbit. We are also discussing therapeutic possibilities currently available in the management of the disease.

Spontaneous cerebrospinal fluid leak at the clivus.

We present a case report of a 60-year-old woman with a spontaneous cerebrospinal fluid leak at the clivus, obesity and no history of trauma. Follow-up imaging scans confirmed enlargement of the defect within the posterior clival framework to the size of 16 × 9 × 4 mm with a suspected meningocerebral hernia. The surgeons used the "two nostrils - four hands" endoscopic operating technique. The patient reported a history of cerebrospinal fluid leaks lasting for 3 years, with increasingly shorter leak-free periods and an increasing incidence of inflammatory complications. The patient recovered without complications, and she was discharged 14 days after the surgery. Good local outcome and improved patient condition were achieved postoperatively.

Clinical and biochemical factors for response to aspirin desensitization in aspirin-induced asthma patients ­ pilot study.

Aspirin desensitization is considered to be an effective and well-tolerated therapy for patients with Non-steroidal anti-inflammatory(NSAIDs)-Exacerbated Respiratory Disease (NERD). The aim of the present study was to investigate the influence of aspirin desensitization on inflammatory cell count in induced sputum and nasal lavage in fifteen NERD individuals subjected to one-year aspirin therapy. The decrease in induced sputum count of eosinophils and macrophages was observed. Clinical efficacy of aspirin therapy in improving nasal symptoms and quality of life in NERD patients was also confirmed.

Aspirin provocation increases 8-iso-PGE2 in exhaled breath condensate of aspirin-hypersensitive asthmatics.

BACKGROUND: Isoprostanes are bioactive compounds formed by non-enzymatic oxidation of polyunsaturated fatty acids, mostly arachidonic, and markers of free radical generation during inflammation. In aspirin exacerbated respiratory disease (AERD), asthmatic symptoms are precipitated by ingestion of non-steroid anti-inflammatory drugs capable for pharmacologic inhibition of cyclooxygenase-1 isoenzyme. We investigated whether aspirin-provoked bronchoconstriction is accompanied by changes of isoprostanes in exhaled breath condensate (EBC). METHODS: EBC was collected from 28 AERD subjects and 25 aspirin-tolerant asthmatics before and after inhalatory aspirin challenge. Concentrations of 8-iso-PGF2α, 8-iso-PGE2, and prostaglandin E2 were measured using gas chromatography/mass spectrometry. Leukotriene E4 was measured by immunoassay in urine samples collected before and after the challenge. RESULTS: Before the challenge, exhaled 8-iso-PGF2α, 8-iso-PGE2, and PGE2 levels did not differ between the study groups. 8-iso-PGE2 level increased in AERD group only (p=0.014) as a result of the aspirin challenge. Urinary LTE4 was elevated in AERD, both in baseline and post-challenge samples. Post-challenge airways 8-iso-PGE2 correlated positively with urinary LTE4 level (p=0.046), whereas it correlated negatively with the provocative dose of aspirin (p=0.027). CONCLUSION: A significant increase of exhaled 8-iso-PGE2 after inhalatory challenge with aspirin was selective and not present for the other isoprostane measured. This is a novel finding in AERD, suggesting that inhibition of cyclooxygenase may elicit 8-iso-PGE2 production in a specific mechanism, contributing to bronchoconstriction and systemic overproduction of cysteinyl leukotrienes.

IgG4-related inflammatory orbital pseudotumors - a retrospective case series.

Orbital diseases may be divided into congenital defects of the orbit, infectious and inflammatory diseases, orbital tumors (including malignant and benign tumors) and injuries. Idiopathic inflammatory syndromes are often encountered within the orbit and are usually classified as orbital pseudotumors. The etiology of pseudotumors of the vision organ is unknown. Infectious agents, autoimmune disorders and improper healing are taken into consideration in the pathogenesis of this disorder. Thanks to detailed studies conducted in recent years, a new disease syndrome was identified in 2001. It is known as IgG4-related disease, and its differentiation is based on the analysis of IgG4 levels in the affected tissues. Orbital locations of the disease were first reported in Japan as late as at the end of 2009. This finding triggered the European studies on this subject. To date, no such studies have been conducted in Poland. The starting study population consisted of 167 patients with isolated infiltrative tumor diseases within the orbital region treated at the Department of Otolaryngology, Head and Neck Surgery of the Medical College Jagiellonian University in Krakow. Detailed analysis and diagnostic screening for IgG4-related disease was performed in a total of 17 patients diagnosed with orbital pseudotumor.

In-hospital mortality in cardiac surgery patients after readmission to the intensive care unit: a single-center experience with 10,992 patients.

OBJECTIVES: Determine if readmission to the intensive care unit (ICU) after cardiac surgery procedures is associated with increased mortality. DESIGN: This was a retrospective non-randomized study to evaluate the cause of readmission and mortality rate in patients readmitted to the ICU after cardiac surgery and to compare the clinical variables of patients readmitted to the ICU who died and those who survived. SETTING: The study was performed in a single university hospital. PARTICIPANTS: This was an analysis of 10,992 consecutive adult patients. Readmission rate to the ICU, mortality rate, the reason for readmission to the ICU, type of surgery, length of stay, cause of mortality, and day of the week of ICU readmission were analyzed. INTERVENTIONS: All patients underwent cardiac surgery at a single center and were discharged after primary stay from the ICU. MEASUREMENTS AND MAIN RESULTS: A total of 197 (1,8%) of 10,992 patients were readmitted to the ICU. In-hospital mortality rate for patients readmitted and not readmitted to the ICU was 23.9% and 4.7%, respectively. The main causes of ICU readmission were cardiac (40%) and respiratory (37%) complications. The mortality rate in readmitted patients who underwent coronary artery bypass graft (CABG) or valve surgery was 26% and 19%, respectively. CONCLUSIONS: Patient readmission to the ICU following cardiac surgery was associated with a 5-fold increase in hospital mortality rate compared to non-readmitted patients. The highest mortality rate was observed among readmitted patients who underwent CABG. Older age, previous myocardial infarction, and initial long length of stay in the post-operative ward were independent risk factors for death after readmission to the ICU.

Immunoglobulin G4-related disease (IgG4-RD) in the orbit: mucosa-associated lymphoid tissue (MALT)-type lymphomas.

BACKGROUND: MALT lymphomas were classified for differential diagnostics of IgG4-dependent disease due to their exceptional predilection to intraorbital localization. Therefore, the goal of our studies was large retrospective analysis of patients diagnosed with MALT lymphomas within the orbital tissues, since no such studies have been conducted in Poland. MATERIAL/METHODS: The starting study population consisted of 167 patients with isolated infiltrative tumor diseases within the orbital region treated at the Department of Otolaryngology, Head and Neck Surgery of the Medical College Jagiellonian University in Cracow. The immunohistochemical assays using anti-IgG, anti-IgG4 and anti-CD138 antibodies were used to estimate the IgG4+/CD138+ and IgG4+/IgG+ ratios. RESULTS: Of all the studied and analyzed patients, a final group of 19 patients with orbital MALT lymphomas was selected to undergo diagnostic examinations for IgG4-related disease. Detailed analysis and diagnostic screening for IgG4-related disease was performed and results meeting the criteria of IgG4-dependent disease were obtained in 10 out of 19 patients with the diagnosis of MALT tumor established on the basis of immunohistochemical assays. CONCLUSIONS: MALT lymphomas are the most common of all lymphomas occurring within orbital tissues. In this study, results consistent with the criteria of IgG4-related disease were obtained in approximately 50% patients with immunohistochemical diagnosis of orbital MALT lymphoma.

[Orbital tumors treated at the University Hospital Otolaryngology Clinic in Kraków between 1997 and 2011]. / Guzy oczodolów w materiale Kliniki Otolaryngologii Szpitala Uniwersyteckiego w Krakowie w latach 1997-2011.

The main aim of the study was to establish the frequency of orbital tumor occurrence in the patients of the University Hospital Otolaryngology Clinic in Kraków as well as to analyze the clinical features, location in the orbit and to identify the group of patients with the highest risk of orbital tumor. The authors retrospectively analyzed 46 patients (29 women and 17 men) between the ages of 23 and 87. This group of patients was compared to a group of 80 patients who were surgically treated at the same clinic 10 years ago and to a group of 70 patients treated 15 years ago. We established that the tumors localized in the orbit were mainly benign. A variety of histological types of tumors arises in the orbit but it was significant that inflammatory pseudotumors were the most common cases in all three groups of patients treated in our clinic now, about 10 and about 15 years ago. Referring to the group of patients at the highest risk, we established that orbital tumors are definitely most common in women than men. It has turned out to be statistically significant that benign tumors were most common in younger patients and malignant in older people. That suggests the conclusion that being female is a risk factor for orbital tumors and age is a risk factor for them being malignant. Comparing different approaches for the resection of orbital tumors, we established that the lateral orbitotomy provides access to orbital tumors in the most common locations (intraconal and in the top corner of the orbit). Malignant and extensive tumors have to be treated by orbital exenteration.

[Extensive neck trauma in material of Otolaryngology Department of the Jagiellonian University in Krakow 2009-2012]. / Rozlegle urazy szyi w materiale Kliniki Otolaryngologii CM UJ w Krakowie w latach 2009-2012.

Isolated laryngeal fractures quite rarely can occur following trauma to the neck region, but because of the variety and dynamic growth of symptoms or possible injury of the main structures on the neck may be life-threatening. The appropriate treatment of these patients is quick surgical intervention proceeded by imaging techniques. Here we report the cases of three patients treated in our Department between 2009 and 2012: two of them with penetrating injury and one with blunt trauma. The appropriate treatment of these patients requires that airway patency be the first priority and if possible quick reconstruction. These cases illustrate the individualized treatment and multidisciplinary approach in managing such cases.

Artificial neural network modelling of the results of tympanoplasty in chronic suppurative otitis media patients.

The application of computer modelling for medical purposes, although challenging, is a promising pathway for further development in the medical sciences. We present predictive neural and k-nearest neighbour (k-NN) models for hearing improvements after middle ear surgery for chronic otitis media. The studied data set comprised 150 patients characterised by the set of input variables: age, gender, preoperative audiometric results, ear pathology and details of the surgical procedure. The predicted (output) variable was the postoperative hearing threshold. The best neural models developed in this study achieved 84% correct predictions for the test data set while the k-NN model produced only 75.8% correct predictions.

[Prospective assessment of circulatory sufficiency of the patients after 3F equine pericardial stentless bioprosthesis replacement]. / Prospektywna ocena zmiany wydolnosci serca u pacjentów z wszczepiona bezstentowa, biologiczna zastawka aortalna wykonana z osierdzia konskiego.

INTRODUCTION: During years more and more advanced Technologies are used for treatment of severe aortic stenosis. One of them is equine pericardial stentless bioprothesis. AIM OF THE STUDY: the aim of the study was prospective assessment of circulatory sufficiency of the patients after 3F equine pericardial stentless bioprothesis replacement (ATS-Medtronic, Inc, Minneapolis, USA). PATIENTS AND METHODS: Patients qualified to valve replacement were qualified to the study. The procedures were performed in general anesthesia and medial thoracothomy. The New York Heart Association (NYHA) scale was analyzed to estimate clinical results of the procedures. RESULTS: 45 patients (10 women and 35 men) aged 23-78 (mean 54 (+/- SD 12.7) were included into the study. Patients were observed during one-year follow up (FU). At the baseline three pts had NYHA II stage, 35 - III and 7 - IV. There was no pts in NYHA I stage. After 3-6 months FU 34 pts were at NYHA I stage (79%) and 9 at NYHA II. After 11-14 FU 33 pts were at NYHA I (80.4%) and 8 NYHA II (19.5%). There was no pts at NYHA IV during 12 months FU (differences between observational periods statistically significant p < 0.001). CONCLUSIONS: During one-year FU after equine pericardial stentless bioprothesis implantation the improvement of NYHA grade was observed.

[Clinical evaluation of complications after implantation of stentless biological equine pericardial bioprothesis]. / Ocena powiklan po wszczepieniu bezstentowej, biologicznej zastawki aortalnej wykonanej z osierdzia konskiego.

UNLABELLED: Stentless bio-protheses are more and more frequently used in patients with severe aortic stenosis, due to good hemo-dynamic parameters and durability after aortic valve replacement (AVR). Aim of the study was the clinical evaluation of complications after surgical AVR using the 3F equine pericardial stentless bioprothesis (ATS Medtronic, Inc, Minneapolis, USA). PATIENTS AND METHODS: 45 patients (10 women, 35 men), aged from 23 to 78 had implanted the bioprothesis. RESULTS: Two patients died in perioperative period, but the bioprotehsis function was correct. In two patients gastrointestinal (GE) bleeding was observed due to anticoagulation therapy. In remaining 41 patients during one year follow-up no complications were noted. CONCLUSIONS: After implantation 3F bioprotehesis two unrelated deaths and 2 GE bleeding complications were observed. Other 41 patients had no complications during 1 year follow-up.