Growth hormone-releasing pituitary microadenoma overshaded by a macroadenoma: a case of double pituitary adenomas and review of the literature.

OBJECTIVES: Double pituitary adenoma is a rare entity that can pose a significant challenge. The incidence of double or multiple pituitary adenomas is ∼1% in autopsy cases and 0.4-1.3% in surgical series. Its definition varies, including 'double adenomas' in the literature in contrast to 'multiple adenomas', which is more specific and suitable. While some authors require separating topographically unique tumours, others have used a looser definition of separate immunohistochemistry. CASE PRESENTATION: We presented the case of a 26-year-old patient with recurrent carpal tunnel syndrome symptoms, with double pituitary adenomas secreting growth hormone (GH) and thyroid-stimulating hormone (TSH). To date, 89 patients have been reported in the literature with symptomatic carpal tunnel syndrome, but only five had GH-TSH secretion. CONCLUSIONS: Double adenoma resection is of great importance for ensuring successful biochemical treatment. To ensure a successful operation, a careful preoperative 3T MRI examination is of great importance.

Normative values for semicircular canal function with the video head impulse test (vHIT) in healthy adolescents.

BACKGROUND: The vHIT device, which has a mechanism based on measuring the VOR gain, helps us to quickly evaluate six semicircular canals. AIMS/OBJECTIVES: The aim of this study was to establish normative values for semicircular canal function with the video head impulse test (vHIT) battery in normal adolescents. MATERIAL AND METHODS: 100 (50 females, 50 males) individuals aged 11-18 years, with a mean age of 14.99 years, were included in the study. RESULTS: As a result of the vHIT evaluations performed with vHIT Otometrics ICS Impulse A/S Taastrup, Denmark, the mean lateral canal vestibulo-ocular reflex (VOR) gain value was 0.96, the mean anterior canal VOR gain value was 0.89, and the mean posterior canal VOR gain value was 0.87, all of which were within the normal value range. CONCLUSION AND SIGNIFICANCE: While the VOR gain values and asymmetry values are within the normal value range and are similar to the literature, no statistically significant correlation was observed between these values and age. As a result, the vHIT battery is an easy, fast, and practical test method that can be used in adolescents.

Gene Expression Profiles of Tumor Necrosis Factor-α and Endothelin-1 in Obstructive Sleep Apnea.

BACKGROUND/AIMS: The aim of this study was to observe the relationship between the gene expression profiles of tumor necrosis factor (TNF)-α and endothelin (EDN)-1 and obstructive sleep apnea (OSA). METHODS: A prospective, cross-sectional study performed at a tertiary-care academic center; 108 patients with snoring and day-time sleeplessness were included in this study carried out in the Otolaryngology Department. All patients were evaluated with 1-night polysomnography (PSG). There were 63 patients with OSA and 45 patients without OSA. In the OSA group, the median apnea hypopnea index (AHI) was 29.1; in the non-OSA group, the median AHI was 2.1. Blood samples were obtained from all 108 patients for the genetic analysis of the expression of TNF-α and EDN-1. PSG findings and gene expression levels were evaluated in both groups. RESULTS: The median (range) age was 46 (20-81) years, BMI 24.9 (15-49), EDN-1 gene expression 0.45 (0.02-67.88) pg/µL, and TNF-α gene expression 1.71 (0.08-59.52) pg/µL. We found that EDN-1 and TNF-α gene expression levels were significantly higher in the OSA group than in the control group (p = 0.009 vs. p < 0.001). CONCLUSION: EDN-1 and TNF-α gene expression levels were associated with the occurrence of OSA.

Functional analysis of ESM1 by siRNA knockdown in primary and metastatic head and neck cancer cells.

BACKGROUND: Genetic factors play a large role in cancer, and thus, there is a great desire to understand the effects of different genes in cancer and to also develop gene therapy for better treatments. Therefore, the development of alternative diagnosis and therapy modalities is of utmost importance. The aim of our study was to illuminate the role of ESM1 (endothelial cell-specific molecule-1, also known as Endocan) in proliferation and migration of head and neck cancer, thus helping to pave the way for new treatment modalities and predictive biomarkers. METHODS: ESM1 expression was shown with immunofluorescence assay using confocal laser scanning microscope in primary and metastatic head and neck cancer cells. ESM1 expression was knocked down by RNA interference in head and neck cancer cells. Knockdown efficiency was evaluated by quantitative real-time RT-PCR and Western blot. Cell proliferation and migration assays were performed by xCELLigence real-time cell analysis system. RESULTS: Immunofluorescence assay showed nuclear localization and high expression of ESM1 in primary and metastatic head and neck cancer cells. ESM1 mRNA and protein levels were significantly decreased in ESM1-knockdown cells compared to control. ESM1-knockdown cells showed reduced proliferation and migration activity when compared to control cells. CONCLUSION: These findings suggest that ESM1 has roles on proliferation and migration of head and neck cancer cells.

Association of Oral Antireflux Medication With Laryngopharyngeal Reflux and Nasal Resistance.

Importance: Laryngopharyngeal reflux (LPR) is thought to be a potential exacerbating factor in upper airway diseases. Objective: To describe the effect of pharmacologic therapy of laryngopharyngeal reflux on nasal resistance. Design, Setting, and Participants: Prospective observational study performed between August 30, 2014, and October 1, 2015, at a tertiary care academic center including 50 patients with Reflux Symptom Index higher than 13 and Reflux Finding Score higher than 7 and 50 controls with no history of LPR and nasal disease. Interventions: Oral antireflux medication was given to the LPR group for 12 weeks. Main Outcomes and Measures: The measurements of total nasal resistance (TNR) were performed by means of active anterior rhinomanometry technique and Nasal Obstruction Symptom Evaluation (NOSE) was assessed. Results: The LPR group had 29 (58%) women and a median age of 41.5 years (range, 18-64 years). The control group had 27 (54%) women and a median age of 38.5 years (range, 19-63 years). After treatment, a significant decrease was observed in all parameters. The median (range) TNR scores of the LPR group before and after treatment were 0.29 (0.12-0.36) and 0.19 (0.10-0.31), respectively. The median TNR score of the control group was 0.20 (range, 0.11-0.32). Whereas the TNR scores of the LPR group were higher than those of the control group before treatment (difference, -0.77; 95% CI, -0.10 to 0.05), they were almost the same after treatment (difference, 0.01; 95% CI, -0.01 to 0.03). The median (range) NOSE scores of the LPR group before and after treatment were 0.29 (0.12-0.36) and 0.19 (0.10-0.31), respectively. The median NOSE score of the control group was 0.20 (range, 0.11-0.32). Conclusions and Relevance: In this study, laryngopharyngeal reflux had a negative effect on nasal resistance and nasal congestion. Treatment was associated with improved subjective and objective nasal findings.

Surgical conditions during FESS; comparison of dexmedetomidine and remifentanil.

To compare dexmedetomidine with remifentanil in functional endoscopic sinus surgery (FESS) in regards to intra-operative bleeding, anesthetic consumption and post-operative recovery. Randomized, double blind study. Tertiary care medical center. Fifty patients with nasal polyposis who had been scheduled for FESS were randomly divided into two groups. In group D (n = 25), dexmedetomidine 1 µg/kg infused intravenous (IV) over 10 min before anesthesia induction, followed by a continuous of 0.7 µg/kg/h infusion during operation. In group R (n = 25), 1 µg/kg remifentanil IV bolus, was administered with induction of anesthesia and continued 0.25-0.50 µg/kg/min during operation. Heart rates, mean arterial pressure, end tidal CO2, end tidal sevoflurane were recorded. The amount of bleeding, surgical field condition for bleeding and the time to reach Aldrete recovery score 9-10 were recorded. Postoperative nausea, vomiting, pain, shivering, sedation were followed up over 24 h. There was no significant difference between groups according to the amount of bleeding during surgery, assessment of surgical field condition, consumption of sevoflurane, scores of postoperative VAS, rates of nausea and vomiting, shivering, demands of additional analgesic medication (P > 0.05). The time to reach Aldrete recovery score 9-10, sedation scores at the postoperative first hour were significantly higher in group D (P = 0.001). We concluded that in comparison to remifentanil, dexmedetomidine during FESS for controlled hypotension is of limited value as it has no additional benefits in terms of control of hypotension and amount of bleeding in the surgical field and it is associated with higher recovery time and first-hour postoperative sedation scores.

Long-term results of one staged multilevel surgery with tongue suspension surgery or one level palatal surgery for treatment of moderate and severe obstructive sleep apnea.

UNLABELLED: The objective of this study is to evaluate and compare the long-term efficacy of the one staged multilevel surgery (MLS) with tongue suspension (TBS) surgery or one level palatal surgery for treatment of moderate and severe obstructive sleep apnea (OSA). This is a prospective cross-sectional study. SETTING: University hospital. Thirty-three patients diagnosed as moderate to severe OSA. Patients, with ≥ 50 % retropalopharyngeal obstruction on the Müller maneuver, were treated with palatal surgeries (PS) and patients, with ≥ 50 % retropalopharyngeal obstruction on the Müller maneuver with ≥ 50 % base of the tongue collapse, were treated with palatal surgeries and tongue suspension surgery (TBS). Patients were evaluated with one night polysomnography before the surgery and 24 months after the surgery. Patients completed Epworth sleepiness scale (ESS), snoring VAS (visual analog scale) before and 24 months after the surgery. Nine-teen patients with a mean age of 46.1 ± 8.3 underwent palatal surgeries (PS) and 14 patients with a mean age of 41.4 ± 8.9 underwent PS plus TBS. Success rate in TBS+PS group was 57.1 % and in PS group was 42.1 %. In both groups total apnea-hypopnea index (AHI) values significantly decreased after 2 years (p < 0.025) but there was no statistically significant difference between TBS+PS and PS groups. Supine AHI levels were reduced statistically significant in both groups postoperatively (p < 0.025). There was not any significant difference postoperatively in non-supine AHI levels in both groups (p > 0.025). There were significant postoperative changes in ODI, AVO2, MOS, ESS, Snoring VAS values in PS group (p < 0.025). In TBS+PS group there was a significant difference postoperatively only in ODI values. Treatment of OSA patients with retropalatal or retropalatal and retroglossal obstruction, in a one staged surgery, is a safe and easy procedure. We have achieved favorable long-term outcomes in moderate-severe OSA patients undergoing both palatal surgery and tongue suspension surgery.

Anterior palatoplasty for selected mild and moderate obstructive sleep apnea: preliminary results.

The aim of this prospective study was to evaluate the long-term efficacy anterior palatoplasty (AP) technique in treatment of patients with mild to moderate obstructive sleep apnea (OSA). Forty-two patients were diagnosed with mild to moderate OSA. Participants were treated with AP for mild or moderate OSA. Patients were evaluated with one night polysomnography before the surgery and 24 months after the surgery. Patients completed Epworth sleepiness scale (ESS), snoring VAS (visual analog scale) before and 24 months after the surgery. Forty two patients with a mean age of 39.2 ± 7.6 were included study. Success rate was 57.1%. Total apnea-hypopnea index (AHI) values significantly decreased after 2 years (p < 0.025). Non-REM AHI and supine AHI values significantly decreased after 2 years (p < 0.025). The oxygen desaturation index changes significantly decreased after AP (p < 0.025). Snoring VAS values significantly decreased after AP (p < 0.025). ESS scores of patients significantly decreased (p < 0.001). We believe that AP is an effective, inexpensive technique for mild and moderate OSA patients.

Epistaxis in geriatric patients.

AIM: Epistaxis is a common emergency in otolaryngology. The aim of this study is to analyze the etiology, management, and accompanying disorders of epistaxis in geriatric patients by reviewing the literature MATERIALS AND METHODS: Data of 117 patients 65 years old and older who presented to the Department of Otorhinolaryngology with active epistaxis between 2004 and 2010 were retrospectively reviewed. Records were evaluated for age, sex, accompanying disorders, drug medication, detailed otorhinolaryngological findings, and management of epistaxis. RESULTS: There were 67 women (57.26%) and 50 men (42.74%) with a mean age of 73.51 years (range: 65-90). Ninety-four (80.34%) patients had accompanying disorders such as hypertension, diabetes mellitus, cerebrovascular disease, sinusitis, chronic obstructive lung disease, nasal polyp, and drug treatment. The bleeding site was anterior in 90 patients (76.92%) and posterior in 16 (13.67%). In 11 patients (9.4%), the bleeding site was not identified. Fifty-seven patients (48.71%) were treated with cauterization, 17 patients (14.52%) with nasal packing, 12 patients (10.25%) with medical treatment, 1 patient (0.85%) with mass excision and nasal packing, and 19 patients (16.23%) with more than 1 treatment method. Six patients (5.12%) were untreated because of the unidentified bleeding point. Bleeding control was performed under local anesthesia in 113 patients (96.58%) and under general anesthesia in 4 patients (3.41%). Twenty-one patients (17.94%) were hospitalized and 3 patients (2.56%) required a blood transfusion. CONCLUSION: Epistaxis is the most common otorhinolaryngological emergency. It must be evaluated carefully to avoid the potential complications resulting from both epistaxis and its associated disorders, especially in geriatric patients.

The comparison of preincisional peritonsillar infiltration of ketamine and tramadol for postoperative pain relief on children following adenotonsillectomy.

OBJECTIVE: To investigate and compare the effectiveness of preincisional peritonsillar infiltration of ketamine and tramadol for post-operative pain on children following adenotonsillectomy. STUDY DESIGN: Prospective randomized double blind controlled study. METHODS: Seventy-five children aged 3-10 years undergoing adenotonsillectomy were included in study. Patients received injections in peritonsillar fossa of tramadol (2 mg/kg-2 ml), ketamine (0.5 mg/kg-2 ml) or 2 ml serum physiologic. During operation heart rate, oxygen saturation, average mean blood pressures were recorded in every 5 min. Operation, anesthesia and the time that Alderete scores 9-10, patient satisfaction, analgesic requirements were recorded. Postoperatively nausea, vomiting, sedation, dysphagia, bleeding scores were recorded at 0, 10, 30, 60 min and 2, 4, 8, 12, 18, 24h postoperatively. Pain was evaluated using modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at fixed intervals after the procedure (15 min and 1, 4, 12, 16, and 24h postoperatively). RESULTS: The recordings of heart rate, mean arterial pressure, nausea, vomiting, sedation and bleeding scores were similar in all groups (p>0.05). The mCHEOPS scores at 10 min, 30 min, 1h, 8h were significantly lower in both tramadol and ketamine group when compared with control (p<0.05). Use of additional analgesia at 10 min and 18 h were higher in control group than ketamine, tramadol group (p<0.05). Dysphagia scores were significantly lower for both ketamine and tramadol group when compared with control group (p<0.05). mCHEOPS, additional analgesia, dysphagia, patient satisfaction scores were similar in tramadol, ketamine groups (p>0.05). CONCLUSIONS: Preincisional injection of ketamine and tramadol prior to tonsillectomy is safe, effective method and equivalent for post-tonsillectomy pain, patient satisfaction, postoperative nausea, vomiting, dysphagia.

Comparison of scores of application methods of the Epworth Sleepiness Scale: self administered or nurse administered.

PURPOSE OF THE STUDY: The aim of this study was to investigate the impact of two different application methods (self or nurse administered) on Epworth Sleepiness Scale (ESS) scores and compare the scores according to their correlations between polysomnographic findings. PROCEDURES: 114 patients agreed to participate by completing the Turkish version of the ESS with 2 different methods of application, but the complete results of polysomnography (PSG) were available for 101 patients. RESULTS: The scores of the nurse-administered ESS were clinically significantly correlated with the apnea-hypoapnea index. Scores of the self-administered ESS were not correlated with any of the demographic and PSG parameters. In the reliability analysis, the scores of the self-administered and the nurse-administered ESS were quite consistent. CONCLUSION AND MESSAGE: We considered that to complete the ESS with the method of nurse administration could change the reliability and sensitivity. In conclusion, the ESS may be a more reliable tool for measuring the severity of excessive daytime sleepiness or obstructive sleep apnea by a change in the administration method.

Unexpected cerebrospinal fluid rhinorrhea after a spinal anesthesia.

A 47-year-old woman presented with a left-sided watery nasal discharge persisting for 3 weeks after an orthopedic operation using spinal anesthesia. The testing of the nasal fluid for ß-2 transferrin confirmed that the leakage was cerebrospinal fluid (CSF). The computed tomographic cisternography revealed a left-sided bone defect in the cribriform plate. Endonasal approach was performed for closing the defect. At 3-month follow-up, CSF rhinorrhea had not recurred. In this report, we present an unexpected CSF rhinorrhea after a spinal anesthesia and discuss the reason of spontaneous leak after spinal anesthesia, as well as discuss current diagnosis and management of CSF rhinorrhea with the composite graft.

Subcutaneous fat tissue thickness of the anterior neck and umbilicus in patients with obstructive sleep apnea.

OBJECTIVE: To investigate the differences in thickness of subcutaneous fat tissue of the anterior neck and umbilicus of patients with and without obstructive sleep apnea (OSA), the relationship between thickness of subcutaneous fat tissue of the anterior neck and umbilicus and polysomnographic findings, and the influence of body mass index (BMI), anthropometric findings, and gender. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary care university hospital. SUBJECT AND METHODS: Seventy-three patients with OSA and 24 non-OSA patients were evaluated with polysomnography for 1 night. Anthropometric parameters and BMI were also investigated. Subcutaneous fat tissue thickness of anterior neck and umbilicus was assessed using ultrasound. The thickness of subcutaneous fat tissue adjacent to the submandibular gland, isthmus, hyoid, suprasternal notch, and umbilicus was measured with ultrasound. Data analysis was performed using SPSS. RESULTS: Apnea-hypopnea index (AHI) was significantly and positively correlated with age (P = .016, r (2) = 0.244), BMI (P < .001, r (2) = 0.416), and anthropometric findings (waist circumference P < .001, r (2) = 0.337; hip circumference P = .008, r (2) = 0.269; neck circumference P = .002, r (2) = 0.309). Minimum oxygen saturation was significantly, negatively correlated with age (P = .002, r (2) = -0.310), BMI (P < .001, r (2) = -0.404), and anthropometric findings (waist circumference P = .005, r (2) = -0.281, hip circumference P < .001, r (2) = -0.353, neck circumference P = .010, r (2) = -0.261). There were no significant differences between the OSA and non-OSA groups with respect to age (P = .178), gender (P = .189), or ultrasonographic findings for subcutaneous fat tissue thickness adjacent to the submandibular gland (P = .480), thyroid isthmus (P = .311), suprasternal notch (P = .950), umbilicus (P = .691), or hyoid (P = .159). Neck circumference (P = .039) and BMI (P = .014) were significantly higher in the OSA group. CONCLUSION: These indicate that anterior neck and umbilical subcutaneous fat tissue thickness may not contribute to the severity of OSA.

Three cases of oropharyngeal tularemia in Turkey.

OBJECTIVE: We aimed to attract our colleagues' attention to the oropharyngeal tularemia, which has been an infrequently diagnosed disease in otolaryngology clinics also becoming widespread in Turkey. METHODS: A retrospective review of database of 3 patients was performed to find patients with Tularemia. The medical files, treatment charts, serological and PCR findings and radiological (magnetic resonance imaging), histopathological records of these patients were reviewed. RESULTS: The study group consisted of 3 oropharyngeal tularemia patients. All of them presented with tonsillopharyngitis and cervical lymphadenitis and all were resistant to beta lactam or cephalosporin group antibiotics. Two patients had magnetic resonance imaging findings. All patients had positive serological tests. Strongly positive serological tests led to the diagnosis of tularemia. All patients had positive PCR and direct fluorescent antibody (DFA) test. All patients responded to systemic streptomycin treatment. CONCLUSION: In the daily practice of an otolaryngologist, it is not usual to diagnose a patient with oropharyngeal tularemia. Tularemia should be considered in the differential diagnosis of massive adenotonsillar enlargement and extensive necrotic cervical lymphadenopathy not responding to beta lactam antibiotics as a result of the rising number of tularemia outbreaks outside the classic endemic areas.