Surgery vs medical treatment in the management of PFAPA syndrome: a comparative trial.

BACKGROUND: Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome is a common disorder in children but there is little or no consensus on its optimal diagnosis and management. OBJECTIVES: To compare the outcome of different management approaches - medical therapy or tonsillectomy. METHODS: The medical records of children diagnosed with PFAPA between 2008 and 2013 were retrospectively reviewed according to the modified Thomas test criteria. Patients were divided into two groups: group 1 for medical treatment - corticosteroids, a single intramuscular injection of methylprednisolone, and group 2 for surgery - tonsillectomy alone or tonsillectomy plus adenoidectomy .The course of the disease including the number and duration of episodes and the presence of remission, was documented. RESULTS: 105 patients (30 in group 1, 75 in group 2) met the study's inclusion criteria. Groups 1 and 2 were followed up for a mean (SD) of 23.6 (11.0) and 24 (10.3) months, respectively. At the end of the follow-up period, the number of episodes was 5.8 (6.3) vs 1.8 (1.9) (P<0.01) and their duration was 2.2 (1.3) vs 1.1 (0.8) days (P=0.03), both of which were significantly lower in group 2.The need for hospitalization during this period was significantly lower for group 2 at 1.1 (2.0) vs 0.1 (0.3) (P<0.01) and the remission rate in group 2 was significantly higher than in group 1 (98.6% vs 56.6%, P<0.01). CONCLUSION: This study demonstrated that surgery is superior to medical treatment for PFAPA in terms of increased remission rates and a decrease in the number and duration of episodes.

Temporomandibular disorders in scuba divers-an increased risk during diving certification training.

The design of a diving regulator's mouthpiece increases the risk of a temporomandibular disorder (TMD) in scuba divers. The total weight of a diving regulator is reflected directly on the temporomandibular joint, causing articular and periarticular disorders. In the current study, the prevalence of TMD in scuba divers triggered during diving certification training is investigated. We also aimed to determine the factors that lead to TMD during diving training and clarify the observation that there is an increased incidence of TMD in inexperienced divers. The study was held between 2006 and 2011. Ninety-seven divers were referred with the complaint of pain around temporomandibular area. The divers were classified according to their diving experience. Symptoms and signs of TMD were graded. Fourteen divers were diagnosed with TMD. Temporomandibular disorder was seen more frequently in inexperienced divers than in experienced divers (P = 0.0434). The most prevalent symptom was an increased effort for mouthpiece gripping. Temporomandibular joint tenderness and trigger point activation were the mostly seen physical signs. Thirteen divers had an improvement with therapy. The increased effort for stabilizing the mouthpiece is a recognized factor in TMD development. Attention must be paid to an association of scuba diving with TMDs, especially in inexperienced divers having a scuba certification training.

Chlamydia trachomatis tonsillopharyngitis.

Reports about the extragenital spread of Chlamydia trachomatis (CT) to oropharynx are limited. We report a male patient with progressive tonsillopharyngitis resistant to amoxicillin/clavulanic acid therapy. The patient presented 9 days after an orogenital and oroanal sexual intercourse with a female sex worker. The microimmunofluorescence revealed CT tonsillopharyngitis, and after completing a one-week course of doxycycline, the patient recovered completely. More cases of CT tonsillopharyngitis may be revealed if attention is paid to an association of sexual activity with enduring tonsillopharyngitis.

[Minimally invasive video-assisted thyroidectomy for treatment of benign thyroid nodules]. / Benign tiroid nodüllerinin tedavisinde minimal invaziv video yardimli tiroidektomi.

OBJECTIVES: This study aims to evaluate patients who underwent minimally invasive video-assisted thyroidectomy (MIVAT) and to discuss the advantages and disadvantages of this technique in the light of literature data. PATIENTS AND METHODS: Between May 2008 and February 2009, 20 patients (18 females, 2 males; mean age 44.5±13.6 years; range 23 to 68 years) who underwent MIVAT using a 4 mm and 30° rigid endoscope and ultrasonic scalpel for dissected the main thyroid vessels were included in the study. Inclusion criteria were benign thyroid nodules of <30 mm and ultrasonographically thyroid volume of <20 ml. RESULTS: The mean length of incision was 2.6±0.5 cm, the mean operation time was 111.7±39.7 min and the mean amount of bleeding was 82.8±84.1 cc. A statistically significantly positive relationship was found between the operation time and the nodule size and the amount of bleeding and also between the length of the incision and cosmetic satisfaction scale scores (p<0.05). However, no statistically significant correlation was found between the operation time and postoperative pain and between the length of incision and postoperative pain (p>0.05). Although 30% of the patients had mild to moderate pain, 50% had moderate pain and 20% had severe pain in the early postoperative period, no patient had pain in the postoperative third day. No postoperative persistent vocal cord paralysis was observed in the patients. CONCLUSION: Minimally invasive video-assisted thyroidectomy is a safe and useful approach in the treatment of the patients with benign thyroid nodules.

Bare serratus anterior free flap in the reconstruction of the partial pharyngoesophageal defect.

Reconstruction of defects of the cervical esophagus is a challenge in head and neck surgery. Several methods have been used: flaps with local tissues, pharyngogastric anastomosis, deltopectoral skin flaps, skin muscle transplant from the pectoralis major, and microvascularized free skin fascial and small intestine flaps. A 81-year-old patient who has a partial pharyngoesophageal defect after resection of laryngeal carcinoma underwent reconstruction with bare serratus anterior fascial free flap. The subscapular artery and vein were anastomosed to the superior thyroid artery and vein. The patient's postoperative recovery went uneventfully. In the endoscopic examination, the defect was completely covered with native mucosa 8 weeks after surgery, and also, there were no stricture and fistula tract in the reconstructed area.Serratus fascial flap is a thin and pliable flap with good and reliable vascularity; it can be used in the reconstruction of partial cervical esophageal defect with its long pedicle. Serratus fascial flap can provide significant epithelialization that cannot be differentiated from native esophagus. We propose that serratus fascial free flap is an important alternative in esophageal reconstructions because it creates minimal donor-site morbidity and it can easily adapt to the defect.

Papillary thyroid carcinoma in a 3-year-old child: case report.

Thyroid cancers account for 0.5-3.0% of all childhood malignancies. These cancers are exceedingly rare at ages younger than 5 years. Although the disease is biologically more aggressive in children when compared with adults, the prognosis is better. There are only few case reports in the literature describing papillary thyroid carcinoma under age 5. In this case report, a 3-year-old child with bilateral multiple masses on the neck that were present for 6 months and who was diagnosed with thyroid papillary carcinoma is presented, and the diagnosis and therapy of the disease is discussed.

The effects of the incision types in myringoplasty operations on cosmesis.

There is no study based on objective measurements about the cosmetic results of myringoplasty operation in medical literature. This study aims to show the differences in the auriculomastoid angle between the operations which were done with postauricular and endaural incisions. The auriculomastoid angle of 20 patients having had postauricular myringoplasty operation were measured both preoperative and postoperative periods. The auriculomastoid angles of 17 patients having had endaural myringoplasty operation were also measured in both preoperative and postoperative periods. Also, the patients were asked whether there was a change in the shape of their ears. It was observed that the increase of the auriculomastoid angles of the patients who had myringoplasty by postauricular incision was statistically significant when compared to the ones having had the operation by endaural incision. Also, the patients who had myringoplasty operation by postauricular incision realized the change in their ears significantly when compared to the other group. In this study, esthetically better results were observed in the myringoplasty operations done by endaural incision than the ones done by postauricular incision. When deciding on the incision type, this should be considered.

Laryngeal mucoepidermoid carcinoma: report of two cases.

Mucoepidermoid carcinoma (MEC) of the larynx is a rare neoplasm, with a review of the literature having disclosed only 83 documented cases. These tumours are believed to develop from ductal elements of the submucosal glands [Gomes V, Costarelli L, Cimino G, Magaldi L, Bisceglia M. Mucoepidermoid carcinoma of the larynx. Eur Arch Otorhinolaryngol 1990;248:31-4]. The most common sites are the floor of the laryngeal ventricle, false vocal folds and anterior comissure [Alavi S, Namazie A, Calcaterra TC, Blackwell KE. Glandular carcinoma of the larynx: the UCLA experience. Ann Otol Rhinol Laryngol 1998;108:485-9]. We describe two cases of MEC of the larynx. One of them was a transglottic and the other one a supraglottic tumour. First patient was treated with total laryngectomy (TL) and right extended radical neck dissection (RND). Second case was treated with supracricoid laryngectomy (SCL) and bilateral posterolateral neck dissection (PLND). Both patients received radiotherapy (RT) and their 1-year follow-up showed no evidence of recurrence or metastasis. The diagnostic and therapeutic aspects of these cases are discussed.

Intracranial abscesses associated with chronic suppurative otitis media.

Intracranial abscesses are serious complications of chronic suppurative otitis media (COM). This study included 32 patients presenting with intracranial abscesses from 780 patients hospitalized for treatment of COM. The 32 patients had 59 intracranial complications. Perisinus abscess (13 of 32) was the most common intracranial abscess, followed by temporal lobe abscess (8 of 32), epidural abscess (7 of 32), cerebellar abscess (6 of 32) and subdural empyema (2 of 32). Headache (93%), fever (87%) and altered mental status (62%) were the most common presenting symptoms and signs, along with symptoms of COM. All patients were treated with intravenous antibiotics and canal wall down mastoidectomy. Cholesteatoma with granulation tissue and bony defects at the sinus plate and/or dural plate were seen in most of the patients. Gram negative bacilli and anaerobes were the most common organisms cultured from the abscesses. Three patients had neurological sequels. One patient died. The early diagnosis of these complications requires a high index of suspicion and imaging studies. A multidisciplinary and coordinated approach is important for the management of these patients.

Comparison of diced cartilage graft wrapped in surgicell and diced cartilage graft wrapped in fascia: an experimental study.

HYPOTHESIS: This study was conducted to compare diced cartilage grafts wrapped in fascia and diced cartilage grafts wrapped in surgicell with respect to their resorption. STUDY DESIGN: Experimental study. METHODS: Eight male Wistar Albino rats were used. After general anesthesia, two different subcutaneous pockets (upper and lower pocket) were prepared in the rat's abdomen. Surgicell-wrapped homograft that was taken from the ear was placed into the upper subcutaneous pocket. Fascia-wrapped homograft which was taken from the ear was placed into the lower subcutaneous pocket. All the rats were killed at the end of 2 months, and the samples were collected to be examined histopathologically. Cartilage mass, foreign body reaction, fibrosis, chronic inflammation, and vascularization were researched. RESULTS: Diced cartilage wrapped surgicell stained negative for glial fibrillary acidic protein (GFAP). Diced cartilage wrapped in fascia stained positive for GFAP. There was a significant difference between two groups with respect to fibrosis, chronic inflammation, and cartilage mass. There was no significant difference between the two groups regarding vascularization. CONCLUSIONS: This study suggests that diced cartilage graft wrapped in surgicell was absorbed, whereas diced cartilage graft wrapped in fascia was not.

Investigation of Helicobacter pylori colonization in laryngeal neoplasia.

Helicobacter pylori has been investigated in several other organ systems and localizations such as the oral cavity, but has not been investigated extensively in squamous cell carcinoma of the larynx, a region that could be directly exposed to the bacterium by the oral route or gastro-esophageal reflux. Only serological studies are available regarding the relation between H. pylori and laryngeal cancer, yielding conflicting results. To our knowledge, there is no study investigating the presence of H. pylori in laryngeal squamous cell carcinoma tissue. The purpose of this study was to investigate the presence of H. pylori in laryngeal squamous cell carcinoma tissue and to investigate the possible role of this organism in the etiopathogenesis of laryngeal cancer. Specimens from 50 patients with laryngeal cancer who underwent total or partial laryngectomy between March 1999 and December 2002 were examined by histopathological and immunohistochemical methods to detect H. pylori. The presence of H. pylori was also investigated histopathologically in 50 benign laryngeal biopsy specimens. In our study, we demonstrated that H. pylori was not present in laryngeal squamous cell carcinoma tissue or in the benign lesions. We could not find any evidence indicating that H. pylori played a role at the tissue level in the pathogenesis of laryngeal carcinoma.

Microscopic thyroidectomy: a prospective controlled trial.

The purpose of this prospective study was to evaluate microsurgical thyroidectomy by comparing it with traditional thyroidectomy. Before surgery, patients were assigned either to the microscopic thyroidectomy group (MT group), with the use of the surgical microscope, or the traditional thyroidectomy group (TT group), without the use of visual magnification. Outcome measures were operative time, intraoperative bleeding and complication rates including injury to the recurrent laryngeal nerve (RLN), the external branch of the superior laryngeal nerve (EBSLN) or the parathyroid glands. Ninety-eight patients underwent thyroid surgery (58 patients in the MT group, 40 patients in the TT group). The two groups were similar in age, sex, surgical procedures and histological findings. There was no difference between the two techniques regarding the operative time and the amount of blood loss. Neither permanent nerve palsy nor persistent hypocalcemia occurred in either group. Transient nerve palsies (RLN and EBSLN) were lower in the MT group (1.7%) compared to the TT group (7.5%), but the difference did not reach statistical significance (P>0.05). Overall transient hypocalcemia was significantly lower in the MT group (1.7%) compared with the TT group (12.5%, P=0.032). If the population was restricted to total thyroidectomy, the rate of transient hypocalcemia was 4.1% in the MT group and 33.3% in the TT group, respectively (P=0.022). In conclusion, microsurgical thyroidectomy is a feasible and efficacious surgical procedure. It significantly reduces the complications without increasing the operating time in thyroid surgery procedures. A major advantage of this technique is the possibility of attaching a camera to the microscope, thereby greatly facilitating teaching.

Management of otogenic lateral sinus thrombosis.

PURPOSE: Lateral sinus thrombosis (LST) is a rare but potentially devastating complication of otitis media. We review the clinical presentation, evaluation, management, operative findings, and outcomes of this serious complication. MATERIAL AND METHODS: A retrospective chart review was performed at a teaching hospital of all patients diagnosed with an otogenic lateral sinus thrombosis between 1992 and 2002. Data on patients with otogenic LST were collected and analyzed. RESULTS: Eleven patients were identified with a diagnosis of lateral sinus thrombosis, and all had a chronic otitis media. The most common presenting symptoms were headache, otalgia, and fever. Radiologic evaluation included computed tomography scan, magnetic resonance imaging, or magnetic resonance venography. All patients had radiographic evidence of LST preoperatively. The thrombosed sinus was on the right side in 6 patients and on the left side in 5 patients. The majority of patients (8 of 11) had a second concomitant intracranial complication. All patients underwent a mastoidectomy. The thrombus was removal in 7 cases, whereas only needle aspiration of the sinus was performed in 4 cases. Gram-negative bacilli and anaerobes were the most common organisms. There were no deaths but sequelae included VI nerve palsy, ataxia, and dead ear. CONCLUSION: LST as a complication of otogenic infections may still pose a serious threat that warrants immediate attention and care. It is frequently associated with other intracranial complications. Contrast-enhanced computed tomography scan and magnetic resonance imaging plays a major role in determining diagnosis and treatment plans. The availability of broad-spectrum antibiotics has improved our management significantly. Conservative surgical intervention including eradication of all perisinus infection and needle aspiration of the sinus seems to be effective.

Isolated laryngeal lymphangioma showing the symptoms of acute epiglottitis.

Lymphangiomas are rare, congenital lesions of the lymphatic system, and about 90% of them are detected by the 2nd year of life. Although the head and neck region is the most common place of presentation, isolated laryngeal lymphangioma is extremely rare. A 37-year-old female patient presented with characteristic symptoms of acute epiglottitis. After her acute symptoms resolved with medical treatment, endoscopy was performed, and a wide, pedunculated mass arising from the epiglottis of the larynx was seen. The mass was totally excised and microscopically diagnosed as lymphangioma. To our knowledge, this is the first such case reported in the literature. In the control examination performed after 9 months, no evidence of recurrence was revealed. This interesting case illustrates that the symptoms of acute epiglottitis in the adult should be further investigated to exclude rare lesions such as lymphangioma.

Determination of the changes in the hypoglossal nerve function after suspension laryngoscopy with needle electromyography of the tongue.

The purpose of this study was to determine changes in the hypoglossal nerve function after suspension laryngoscopy with needle electromyography of the tongue. This study also attempted to determine the possible relationship between the predictive factors of intubation difficulty by using the intubation difficulty scale, which was introduced by Adnet et al., duration of suspension laryngoscopy and changes in hypoglossal nerve function after suspension laryngoscopy. The study was performed on 39 patients who underwent suspension laryngoscopy for benign glottic pathology. Pre-operative airway assessment was evaluated by the intubation difficulty scale and the duration of suspension laryngoscopy was recorded. Needle electromyography of the tongue was performed three or four weeks after the suspension laryngoscopy. After needle electromyography of the tongue, increased polyphasia was found in 13 patients (33 per cent), bilaterally in three of them. The interference pattern was reduced in two of these 13 patients. There was no statistically significant difference in predictive factors of intubation difficulty and the duration of the operation between these 13 patients with increased polyphasia and the remaining 26 patients with completely normal electromyography findings. These findings show that, in spite of normal clinical tongue function, subclinical changes can be detected by needle electromyography of the tongue after suspension laryngoscopy.

Antibiotic prophylaxis in clean neck dissections.

This study was designed to evaluate the effects of a prophylactic antibiotic regimen on the incidence of wound infection after clean neck dissections. A prospective series of 57 patients undergoing clean neck dissections with the use of perioperative ampicillin-sulbactam for 24 hours was compared with an historical control group of 51 patients undergoing clean neck dissections with no perioperative antibiotic use. The outcome variable was the incidence of post-operative wound infection. The two groups were similar for factors reported to influence the rate of post-operative wound infection. Wound infection occurred in one patient (1.7 per cent) in the study group and in seven patients (13.3 per cent) in the control group, the difference was statistically significant (p = 0.02). These data suggest that the use of a perioperative antibiotic for 24 hours in patients undergoing clean neck dissection results in significant reduction in the incidence of post-operative wound infection.

Incidence of occult thyroid carcinoma metastases in lateral cervical cysts.

PURPOSE: To establish the incidence of thyroid carcinoma metastasis in adult patients presenting with apparently benign cervical cysts. The authors report their experience with four cases of papillary thyroid carcinoma who present with a lateral cervical cystic mass and no palpable disease in the thyroid gland. MATERIALS AND METHODS: A retrospective review of patients undergoing surgery for solitary cervical cysts in our clinic from 1994 to 2002 was performed. Patients with a clinically obvious primary malignancy, age less than 16 years were excluded from the study. RESULTS: Thirty-seven patients were identified. A diagnosis of benign cervical cyst was shown by histological examination of the resected specimen in 32 patients (86.4%), with a mean age of 34 years (range, 16-59 years). A diagnosis of squamous cell carcinoma metastasis arising from an occult tonsillary primary was confirmed histologically in one patient (2.7%). Papillary thyroid carcinoma metastasis was confirmed by histological examination of the resected specimen in 4 patients (10.8 %), with a mean age of 29 years (range, 18-37 years). Diagnostic studies performed included ultrasound, computed tomography scan, fine-needle aspiration (FNA), and excisional biopsy. FNA was found to be helpful in only one of the 3 cases with papillary thyroid carcinoma metastasis. Final histopathological examination exhibited primary focus in the thyroid gland in all 4 patients, with a mean size of 0.5 cm (range, 0.3-0.8 cm). CONCLUSION: Our data indicate that nearly 1 out of every 10 lateral cervical cysts in young adult patients represents lymphatic metastases from occult thyroid carcinoma. An excisional biopsy for definitive diagnosis should be undertaken without prolonged delay, even if FNA does not reveal malignancy.

Should hyperbaric oxygen be added to treatment in idiopathic sudden sensorineural hearing loss?

At present, there is still no agreement about the therapy of idiopathic sudden sensorineural hearing loss (ISSHL). Hyperbaric oxygen (HBO) is used in the therapy of ISSHL to increase the partial oxygen pressure and the oxygen concentration in the inner ear and also to improve the blood profile and the microcirculation. In our prospective randomized study, we aimed to investigate the therapeutic effects of HBO therapy in the 1st 2 weeks of the onset of ISSHL. Fifty-one hospitalized patients with confirmed ISSHL who had received therapy were grouped randomly into two groups. Twenty-one patients (group I) received steroids, plasma expander dextrans (rheomacrodex), diazepam, pentoxiphylline and salt restriction, and 30 patients (group II) received the same basic treatment with the addition of HBO therapy. Audiological assessments of the patients were performed before and after the treatment. The hearing gains at frequencies of 250, 500, 1,000, 2,000 and 4,000 Hz were calculated separately. The level of hearing loss at the five frequencies was assessed in three groups at the first visit: equal or below 60 dB, between 61-80 dB and equal or above 81 dB. The average of the mean hearing gains at the five frequencies of the patients according to the age groups in group II was compared. The mean hearing gains at the five frequencies were compared between the two groups, and statistically significant improvement was detected in all the frequencies except at 2,000 Hz in group II. The mean hearing gains in group II were found to be significantly high in patients with initial hearing levels up to 60 dB in comparison to patients with initial hearing levels below 60 dB. When age groups and mean hearing gains were compared, there was no statistically significant difference in group I. In group II, the mean hearing gains were 39.1+/-18.3 dB in patients younger than 50 years and 22.7+/-11.3 dB in patients older than 50 years ( P=0.044). In conclusion, the addition of HBO therapy to conventional treatment modalities significantly improves the outcome of ISSHL, especially at the frequencies of 250, 500, 1,000 and 4,000 Hz and in hearing loss of above 61 dB. Furthermore, HBO therapy was found to be more effective in patients younger than 50 years.

A randomized controlled trial of early oral feeding in laryngectomized patients.

OBJECTIVE: To evaluate the safety and efficacy of early oral feeding by comparing it with feeding through primary tracheoesophageal puncture after total laryngectomy with primary pharyngeal closure. STUDY DESIGN: A prospective, randomized, controlled study. METHODS: Patients who underwent total laryngectomy with primary pharyngeal closure and who were candidates for primary voice restoration (an in whose cases primary tracheoesophageal puncture [TEP] was created) were included. After total laryngectomy, patients were randomly assigned to either the oral group (study group) or the TEP group (control group). Patients in the oral group were fed orally with a clear liquid diet on the first postoperative day, then advanced to a regular diet, whereas patients in the TEP group were fed through tracheoesophageal puncture and received nothing orally until the seventh postoperative day; then they were fed orally if fistula had not occurred. Standard criteria for discharge were used for all the patients. RESULTS: During a 3-year period, 67 patients were enrolled in the trial, and complete data were available for 65 patients (32 patients in the oral group, 33 patients in the TEP group). The two groups were similar for factors reported to influence the rate of pharyngocutaneous fistula. In three (9%) patients in the TEP group, fistula occurred on the 5th, 7th, and 14th postoperative days, respectively. Two (6.2%) fistulas occurred in the oral group on the sixth and eighth postoperative days, respectively. In patients without fistula, the mean length of hospital stay was 7.6 days (range, 4-19 d [SD = 3.1 d]) for the oral group and 8.2 days (range, 7-18 d [SD = 2.6 d) for the TEP group. There was no significant difference between two groups for either the incidence of fistula or the length of hospital stay. CONCLUSIONS: Initiation of oral feeding on the first postoperative day in patients undergoing total laryngectomy with primary pharyngeal closure is a safe clinical practice. However, it does not shorten the length of hospital stay for these patients.