Anti-estrogen therapy for hereditary hemorrhagic telangiectasia - a long-term clinical trial.

STATEMENT OF PROBLEM: Hereditary hemorrhagic telangiectasia (HHT) is associated with recurrent epistaxis in 90% of the cases. Good response to hormone treatment has been documented, although its use remains controversial. The aim of this study was to examine the efficacy of an anti-estrogenic agent, tamoxifen, in the treatment of HHT-associated epistaxis. METHOD OF STUDY: Out of 46 patients with diagnosis of epistaxis due to HHT who started treatment with tamoxifen 20 mg/d, 38 patients completed a mean of 23.4 months of treatment. All patients filled out a self-assessment questionnaire of rhinologic Quality of Life and epistaxis grading scale. MAIN RESULTS: The bleeding score and the Quality of Life score improved. Hemoglobin concentration also improved. None of the patients needed blood transfusions during the treatment period. Only one patient had minor side effects of the drug. PRINCIPAL CONCLUSIONS: Tamoxifen appears to be an effective agent for the treatment of epistaxis due to HHT.

Sublabial approach for columellar reconstruction in corrective rhinoplasty.

Columellar reconstruction is a challenging endeavour, both functionally and aesthetically. The aim of this study is to present a novel technique for columellar reconstruction via the sublabial approach. Thirty-two patients (21 men, 11 women, mean age 33.8) with columellar collapse underwent columellar reconstruction via the sublabial approach. Following an upper gingivo-buccal sulcus incision, a tunnel was created through which a cartilage graft, preferably septal, was introduced and fixed. An additional crescent-shaped graft was introduced to secure the fixed graft into position. Average operating time was 35 min for septal grafts, and 55 min for conchal grafts. The mean duration of follow up was 21 months. Postoperative complications included graft absorption in two cases (6.25%), graft extrusions in two cases (6.25%), and postoperative infection in one case (3.12%). These complications were encountered at the beginning of our learning curve. Following technical modifications, these complications were virtually eliminated. Precise control on recipient pocket dimensions, proper graft fixation and avoidance of graft visibility are strongly recommended. In conclusion, columellar reconstruction via the sublabial approach is an anatomic, minimally invasive, time-saving procedure. The operative technique is easy to perform and can be rapidly mastered. It provides structural support, shape, height, and projection to the tip lobule, and the resultant scar is cosmetically superior. It is particularly advantageous in cases of previous septal operations and septal perforation.

[(123)I]-FP-CIT SPECT and olfaction test in patients with combined postural and rest tremor.

Mixed-type tremors pose a clinical diagnostic challenge. The aim of the study was to better characterize patients with combined postural and rest tremor. Patients were categorized into four groups: essential tremor (ET) (n = 7), combined rest + postural tremor (n = 17), PD (n = 17), and control subjects (n = 9). All underwent the University of Pennsylvania Smell Identification Test (UPSIT). The mixed-tremor group was also evaluated with SPECT imaging using the dopamine transporter (DaT) ligand (123)I-labeled FP-CIT. There was no significant difference in olfaction scores between the mixed tremor and essential tremor groups (23.2 +/- 6.6 vs 21.7 +/- 4.9) or between these groups and controls (27.2 +/- 5.0). The patients with PD had significantly lower scores than all the other groups (13.7 +/- 5.4, p < 0.001). Of the 12 patients with mixed tremor evaluated by SPECT, 9 had normal findings. This study suggests that rest tremor is part of the spectrum of ET, even in patients with long-standing disease. However, in a minority of patients, there might be transformation of ET-PD.

[The endoscopic approach to isolated sphenoid sinus disease].

UNLABELLED: We reviewed the records of 38 patients aged 16 to 76 years with isolated sphenoid sinus disease who were treated by intranasal endoscopic sphenoidotomy at our hospital during the period 1992-1997. Diagnosis was made on the basis of history rigid nasal endoscopy and computed tomography (CT) scan of the sinuses. Headache was the main symptom in 29 (76%) patients. Other complaints were rhinitis, cough, nasal obstruction and nasal bleeding. Sphenoidotomy was performed endoscopically, directly through the area of the natural ostium. Acute or chronic sinusitis was found in 57% of the patients, cysts in 13%, polyps in 10%, mucocele in 8%, and fungal infection, pituitary adenoma, inverted papilloma and adenocarcinoma, in 3% each. Surgical results were excellent. The endoscopic approach proved to be both safe and effective. CONCLUSION: Sphenoid sinus disease is mostly inflammatory in origin. The endoscopic approach to the sphenoid sinus is currently the most appropriate method of surgery for an isolated sphenoid lesion.

Reduced expression of activin A in focal lymphoid agglomerates within nasal polyps.

It has been previously reported that activin A, a homodimer of the betaA inhibin subunit, is secreted by stromal cells from mouse bone marrow and causes apoptotic death of mouse plasmacytoma tumor cells. Recent in vitro studies have also implicated this cytokine in the suppression of normal B-cell lymphopoiesis. In this study we examined the occurrence of activin A in nasal polyp tissues that present a combination of epithelium, mesenchyme, and vascular endothelium, with frequent massive hemopoietic infiltration. Anti-betaA-chain antibodies strongly stained epithelial mucous glands and some endothelial cells, and diffusely stained the polyp stroma. Normal adult conchae were similarly stained, whereas activin A was not detected prenatally by immunostaining of nasal tissues. Staining specificity was substantiated by ligand competition assays. Detailed examination of the inflammatory polyp infiltrate showed that activin A staining was reduced in sites of focal infiltration of B-lymphoid cells. It is therefore implied that local accumulation of a large number of B-cells is associated with relatively low activin A expression.

Histological changes in the cervical lymph nodes after radiotherapy.

Radiotherapy to the neck is frequently employed in the treatment of malignancies, sometimes alone and sometimes before or after surgery or with or without chemotherapy. We checked the histopathological changes in the neck after radiotherapy, dividing the changes into two groups. One with short-term changes between six months to one year, and the second group with long-term changes after more than six years. We compared these two groups with a control group without radiotherapy. The changes in the long-term group were more pronounced than in the short-term group, with more stromal fibrosis, vascular changes, and specially lymph nodes smaller than one centimeter. Thus, bigger lymph nodes (more then one centimeter) are more radiosensitive and become smaller after six years.

Capsular collagen staining of follicular thyroid neoplasms by picrosirius red: role in differential diagnosis.

A key criterion in the diagnosis of thyroid follicular carcinoma is capsular invasion, but invasion cannot always be demonstrated histologically. Since invasion is likely to evoke reactions in the capsular collagen, we examined the effects of invasion on capsular collagen with the picrosirius orange-red (PSR) staining technique for collagen. Under polarized light, the color of PSR-stained collagen varies as a function of the structural and biochemical properties of the collagen fibers. Capsules of widely invasive carcinomas (n = 10), minimally invasive carcinomas (n = 10), and adenomas (n = 28) were stained with the PSR method. Carcinomas were assessed along the thickened capsule for sites of definite invasion, minimal invasion, and no evidence of invasion. In adenomas, sites of thickened capsules (similar to carcinomas) were compared to sites of thin capsules. All foci were evaluated for the color and color intensity of collagen fibers. We found a significantly higher frequency of yellow-green collagen fibers than of orange-red fibers at sites of invasion, whereas orange-red fibers significantly predominated at non-invaded sites. In a minority of cases both colors occurred but the non-dominant color was of lesser intensity in all but 1 case. There were no significant differences in staining between minimally and widely invasive carcinomas. Thick capsules of adenomas consistently stained with an intense orange-red color, although weakly stained yellow-green fibers were also observed in some of these cases. We conclude that PSR staining can provide diagnostically useful information in capsular samples of carcinomas, when both color and color intensity of PSR staining are evaluated at the same site. Specifically, intense yellow-green birefringence of collagen in a thickened capsule is additional evidence for capsular invasion.

Neck-dissection surgical specimens treated by lymph node revealing solution.

The detection of metastatic lymph nodes in cancer patients is essential for determining the cancer stage, and thus, the therapeutic modalities. However, very small lymph nodes can easily be missed during routine examination. We described a "Lymph Node Revealing Solution" (LNRS) that helps to detect tiny lymph nodes in neck dissection specimens. Twenty-one consecutive specimens of neck-dissection were investigated. The entire surgical specimen, fixed at first in formalin, was searched for lymph nodes by the traditional method. These were excised and sent for processing. The remaining tissue was immersed for 24 hours in LNRS. The lymph nodes stood out as white chalky nodules on the background of the yellow fat. They were then excised, and examined. A total of 227 lymph nodes were detected by the traditional method; 38 (17%) were positive for metastasis. Using the LNRS method, an additional 72 nodes were identified, among them 8 (11%) were positive for metastases and 2 cases were upstaged. LNRS is an inexpensive and easy method of detecting tiny lymph nodes; it enhances significantly the yield of normal and metastatic nodes of neck-dissection specimens and helps to establish a more accurate staging.

Mucus retention cyst of the maxillary sinus: the endoscopic approach.

OBJECTIVE: To present our experience of endoscopic surgery for symptomatic mucus retention cyst of the maxillary sinus. DESIGN: Retrospective study. SETTING: Teaching hospital, Israel. PATIENTS: 60 patients with 65 symptomatic cysts of the maxillary sinus who were operated on endoscopically. Only patients with large cysts that filled at least 50% of the sinus space were included. INTERVENTION: A rigid nasal endoscope was used in all cases; most of the cysts were removed through the natural sinus ostium. RESULTS: Cysts recurred in only two patients during the first postoperative year. There were no complications from the procedure. CONCLUSION: The endoscopic approach to the treatment of maxillary sinus cyst is associated with a low rate of recurrence (3% in this study) and no complications, and we recommend it as the surgical procedure of choice.

Clinicopathologic study and classification of vocal cord cysts.

Cysts of the true vocal cords are less common than other laryngeal cysts. They are usually easily recognized and managed. Patients present with complaints of hoarseness and/or dyspnea. We report our experience with 41 cases of cysts located in the true vocal cords. Clinical and histological aspects are reviewed and discussed. A new histological classification is proposed: A: cysts lined by columnar epithelium with mucous content; B: lined by columnar epithelium with cilia; C: lined b squamous epithelium without keratinization; D: lined by squamous epithelium with keratinization.

Endoscopic transnasal transsphenoidal microsurgery versus the sublabial approach for the treatment of pituitary tumors: endonasal complications.

OBJECTIVE: To evaluate the nasal complications after transnasal transsphenoidal operations for pituitary tumors, comparing two surgical techniques: traditional sublabial transseptal and endoscopic transseptal techniques. STUDY DESIGN: We retrospectively evaluated by self-reported questionnaire and endoscopic examination the nasal condition of 40 consecutive patients with pituitary tumors: 20 patients had endoscopic surgery and 20 had surgery with the traditional sublabial technique. RESULTS: Compared with the traditional technique, the endoscopic approach was associated with a shorter operative time (about 40 min), shorter hospitalization time (about half), absence of recurrent epistaxis snoring and denture problems, and lower incidence of septal perforation, synechia, and crust formation. Furthermore, loss of nasal tip projection was found only in the group that had surgery with the sublabial technique. CONCLUSIONS: Endoscopically guided transseptal transsphenoidal surgery is simple to perform and time-saving, and it results in fewer nasal and denture complications than the sublabial technique. At the same time, it allows the surgeon all the benefits of the binocular microscopic surgical field that are associated with the traditional approach.

A new rapid technique for the fixation of thyroid gland surgical specimens.

One of the main diagnostic problems in thyroid pathology is to distinguish between follicular adenoma and follicular carcinoma. Thorough sampling of the nodule's capsule is recommended in order to identify capsular invasion. However, during the hardening of the tissue, by the usual fixatives the capsule shrinks and rolls downwards and sometimes the capsule separates from the remaining tissue. The present work evaluates the use of "Lymph Node Revealing Solution" (LNRS) for the rapid fixation (2h) of different thyroid lesions as compared to that of formalin. Fifty-one unselected consecutive cases of thyroid nodules, which included various benign and malignant lesions, were examined. Each specimen was cut in two equal parts; one was fixed in LNRS, the other in formalin. Fixation in LNRS for 2 hours gave adequate results in sectioning and staining of the tissue, and excellent immunostains. Its advantage over formalin is the conservation of the natural relationship between the capsule and the rest of the tissue, on the same plane, as well as the short time required for the final diagnosis.

Supraglottic carcinoma: a retrospective study of 114 patients.

We retrospectively evaluated the management of supraglottic carcinoma at our centre during the last 35 years to determine the preferred mode of treatment. A review of the medical records yielded 114 patients with supraglottic T1 and T2 carcinoma who were diagnosed and treated in the Departments of Otolaryngology, Head and Neck Surgery, and Oncology between 1959 and 1993. Of these, 47 (41.2%) had T1 carcinoma (stage I) and 67 (58.8%) T2 (stage II). Treatment varied among radiotherapy, surgery, or combined radiotherapy and surgery. Twelve patients underwent elective neck dissection, one of whom (8.3%) was found to have occult metastases. Local failures were noted in 22 patients (11 T1: 11 T2), three of whom also had neck metastases. All except one T2 patient received radiotherapy. Radiotherapy yielded the best survival rates for T1 disease as combined therapy did for T2. Five-year recurrence rates for T1 patients were 35% for those treated by radiotherapy and 42% for those treated with combined therapy; corresponding figures for T2 patients were 39% and 28%. We suggest that patients with T1 supraglottic carcinoma be managed with radiotherapy and patients with T2 with combined therapy. We believe there is no need for elective neck dissection, especially in T1.

Endoscopic transseptal transsphenoidal surgery for pituitary tumors.

OBJECTIVE: Transseptal transsphenoidal surgery of pituitary tumors is a well-established surgical technique. The sublabial approach and the open rhinoplasty approach are most commonly used. In both cases, the surgical avenue is along the entire length of the nasal septum, removing both nasal cartilage and the vomer. Septal perforations and upper dental anesthesia are frequent complications of the standard approaches. We describe our initial experience in using the nasal endoscope for the first stage of the operation. METHODS: A nasal endoscope was used to open the anterior wall of the sphenoid sinus. Our initial incision was in the posterior third of the septum, removing only the vomer. After the sphenoid sinus was opened, we inserted a speculum and proceeded with the operation with an operating microscope. After the speculum was in place, it was easier to proceed with the microscope, which allows binocular vision and bimanual operation. RESULTS: The procedure was used for our most recent 14 consecutive patients with pituitary adenomas. No complications related to the approach were encountered for any of the patients in follow-up monitoring. CONCLUSION: The endoscopic transseptal approach to the sphenoid sinus for pituitary surgery was found to be easy, time-saving, and without septal or sublabial complications.

Objective and subjective nasal airflow.

PURPOSE: This study was designed to assess whether a correlation exists between the rhinomanometric measurement of nasal resistance, nasal airflow, and the subjective sensation of airflow. MATERIALS AND METHODS: Sixteen patients with recurrent maxillary sinusitis were examined before and after uncinectomy during functional endoscopic sinus surgery. Subjective nasal sensation of airflow was assessed by means of a visual scale before and after uncinectomy. Rhinomanometry was performed three times for every patient: before anesthesia, and before and after uncinectomy. The subjective nasal sensation of airflow was compared with the nasal airflow and resistance to flow as measured by rhinomanometry. RESULTS: Rhinomanometric measurements were almost the same before and after uncinectomy, with no significant difference, whereas patients reported a significant improvement in nasal airflow. CONCLUSION: Rhinomanometric measurements of nasal airflow and resistance often have no correlation to the patients's sensation of airflow. However, because it is the patients' ultimate concern to breathe more comfortably, the rhinomanometer has little clinical value.

Inverted papilloma of the nose and paranasal sinuses: a study of 56 cases and review of the literature.

Over a period of 32 years, 56 patients with inverted papilloma of the nasal cavity and paranasal sinuses were diagnosed and treated at Beilinson Medical Center, Israel. Four patients (7%) had an associated malignancy. Several surgical approaches were used: limited intranasal excision in 5 patients with an 80% failure rate, a Caldwell-Luc approach in 21 patients with a 48% recurrence rate, and lateral rhinotomy with medial maxillectomy in 18 patients with only a 22% failure rate; a selected group of 9 patients underwent an endoscopic procedure, with a 22% recurrence rate. Our results and a review of 19 published reports suggest that medial maxillectomy via lateral rhinotomy remains the treatment of choice for most cases of inverted papilloma. The role of endoscopic excision in selected patients is discussed.

Isolated sphenoid sinus changes--history, CT and endoscopic finding.

This study reviews the records of 21 patients with isolated sphenoid sinus disease who were treated by rigid endoscopic sphenoidotomy at the Nose and Sinus Unit, Department of Otolaryngology of Beilinson Medical Center, Israel. Diagnosis was made on the basis of history, rigid nasal endoscopy and computed tomography (CT) scan. The most frequent symptom was headache; no instances of 'pathognomonic' headache were found. Sphenoidotomy was performed through the area of the natural ostium. The pathological finding was infection in 11 patients, cyst in four patients, polyps in three patients, mucocoele in two, and inverted papilloma in one patient. Surgical results were very good. Endoscopic sphenoidotomy proved to be safe, with minimal blood loss, reduced operating time, decreased morbidity, and short post-operative hospitalization.

[Endoscopic treatment of maxillary sinus cysts].

Maxillary sinus cysts are common lesions usually found in routine x-rays of the teeth and sinuses. Although most patients are asymptomatic, there may be headache or periorbital or facial pain. Traditionally, these cysts have been treated by puncture and aspiration, or excision via intranasal antrostomy or Caldwell-Luc operation 23 patients with maxillary sinus cysts who presented with facial pain were treated by endoscopic surgery. During followup of 1 year the cyst recurred in only 1 of the patients (after 2 months). We recommend endoscopic removal of maxillary sinus cysts as the treatment of choice.

T1 glottic carcinoma involving the anterior commissure.

This study reviews the records of 56 patients with early glottic carcinoma involving the anterior commissure (T1N0M0) who were treated between 1958 and 1988 at Beilinson Medical Center. Five- and 10-year survival rates were 82% and 60%, respectively. Most failures were local (15 patients). In addition, three patients who were treatment failures had neck lesions (regional failure) and one had lung lesions (distant metastases). All 56 patients received irradiation as the only mode of initial treatment. The effectiveness of irradiation for anterior commissure lesions is therefore evaluated. The study supports previous reports suggesting that glottic carcinoma involving the anterior commissure is associated with a high rate of treatment failure.

Chronic rhinitis in children.

One hundred and fifty-one children aged 2-6 years old suffering from chronic rhinitis were followed and treated for periods of 3-6 months. Seventy-five children were treated with antihistamines (AH) and 76 with antibiotics (AB). Significant statistic difference was found between pre-school children and school children. The differences were both with the nature of the symptoms, and reaction to treatment. While 49% of the school children recovered with AH treatment, only 14% of the pre-school children did. On the other hand, 58% of the pre-school children recovered with AB treatment while only 35% of the older children did. From our results it is clear that in many children bacterial infection is the cause for chronic rhinitis. In pre-school children it is the main cause, while in older children it is the cause in about a third of the cases. It is also important to remember that although allergy might be the basic reason for rhinitis, in certain age groups a secondary bacterial infection might interfere with the efficiency of antiallergic treatment.