Hearing impairment in systemic sclerosis patients-what do we really know?

Background

Systemic sclerosis (SSc) is a disease of a very heterogeneous clinical picture and immunological profile with progression rate that varies between individuals. Although hearing deterioration is not a complaint that comes to the fore in SSc patients, as it is not life-threatening compared to many other more severe symptoms of this disease, it can significantly impair the quality of life. Medical literature concerning this problem is rather scarce.

Materials and methods

In this article we systematically reviewed the medical publications concerning hearing impairment in patients with systemic sclerosis to evaluate current understanding of this complex problem. Following PRISMA guidelines a total of 19 papers were found and analysed including 11 original studies and 8 case reports.

Results

Although it seems that hearing impairment in SSc patients is relatively more common than in the general population, based on the analysis of available literature, no firm conclusions regarding its frequency and pathomechanism can be drawn yet. Microangiopathy leading to damage to the sensory cells of the inner ear is suspected to be the main mechanism of hearing loss, although damage to the higher levels of the auditory pathway appears to be underestimated due to incomplete audiological diagnosis.

Conclusion

Undoubtedly, the reason for the difficulty in such an evaluation are the complex and still not fully elucidated pathomechanism of SSc, the individually variable dynamics of the disease and the unique heterogeneity of symptoms. Nevertheless, further studies in larger and appropriately selected groups of patients, focused more on the dynamics of microangiopathy and not solely on clinical symptoms could provide answers to many key questions in this regard.

Haemangiopericytoma-like tumor of the nasal cavity treated by endoscopy - a case report

Haemangiopericytoma (HPC) is an uncommon, vascular tumor derived from Zimmerman pericytes surrounding blood vessels. HPC constitute around 1% of all tumors of vascular origin and may appear anywhere, 5% of them can be situated in nasal cavity. Tumor location within the head and neck predispose to its benign character and improves prognosis. This case report presents the case of 33-year-old patient with haemangiopericytoma-like tumor of the nasal cavity, presented symptoms of impaired nasal breathing and recurrent epistaxis. Tumor was excised with 0 degree endoscope. The follow-up recurrence-free period was 2 year 6 months and shows this is effective way of treatment. Described in the literature late recurrences and metastases reminds that regular, life-long observation is mandatory.

Intraoperative bleeding during endoscopic sinus surgery and microvascular density of the nasal mucosa

PURPOSE

To evaluate the correlation between quality of the surgical field, intraoperative bleeding during endoscopic sinus surgery (ESS) and the density of microvasculature of the nasal mucosa.

MATERIAL/METHODS

Nasal mucosa of 30 patients, operated for chronic rhinosinusitis, was biopsied to assess expression of CD34 antigen on vascular endothelium. Quality of surgical field was evaluated with Fromm-Boezaart scale at mean arterial pressure (MAP) of 70-80 mmHg. If at this MAP surgical field quality was not satisfactory further reduction of hemodynamic parameters was performed until 'bloodless surgical field' (grade 2 or lower) was achieved. The rate of intraoperative bleeding was calculated from the ratio of total blood loss and the operative time. The extent of the disease was assessed according to computed tomography findings using Lund-Mackay staging system.

RESULTS

Significant positive correlation (Spearman correlation test; p<0.05) was found between CD34 antigen expression and quality of surgical field at MAP between 70 and 80 mmHg as well as the rate of intraoperative bleeding. More intense reduction of MAP was necessary to achieve 'bloodless surgical field' in patients with high CD34 expression than in those with moderate and low expression. Lund-Mackay score correlated with quality of surgical field but not with the rate of intraoperative bleeding.

CONCLUSION

During ESS, it is microvascular density of the nasal mucosa rather than the extent of the disease that contributes to the intensity of intraoperative bleeding, although both factors negatively influence the quality of surgical field.

Minimally invasive transnasal medial maxillectomy for treatment of maxillary sinus and orbital pathologies

CONCLUSION

Minimally invasive transnasal medial maxillectomy with preservation of the nasolacrimal duct may provide an alternative method for surgical treatment of selected maxillary sinus and inferior orbit pathology if more extensive endonasal or external approach procedures are to be avoided.

OBJECTIVES

To present a modification of the transnasal endoscopic approach to the maxillary sinus leading through its medial wall, anteriorly to the nasolacrimal duct that considerably improves access to the antero-inferior part of the maxillary sinus and entire orbital floor. To discuss indications for the procedure along with surgical outcome after at least 12 months of follow-up.

METHODS

A total of 22 selected patients with extensive/refractory inflammatory maxillary sinus disease that could not be cleared completely through middle meatal antrostomy or pathologies of the inferior orbit that required uncompromised access to the orbital floor were operated with this method. The effectiveness of the treatment was evaluated through clinical symptomatology and endoscopic examination to confirm eradication of the disease.

RESULTS

The presented method allowed for good overall symptom control and eradication of disease confirmed endoscopically in about 90% of cases with an inflammatory type of disease. The visualized reach within the maxillary sinus with commercially available endoscopic instruments was conspicuously improved as compared with middle meatal antrostomy.

Endoscopic treatment of adversely located osteomas of the frontal sinus

OBJECTIVES

We assess the utility and limitations of an endoscopic technique in the treatment of osteomas that are considered difficult to manage endoscopically, ie, those located superiorly or laterally in the frontal sinus, extending beyond a virtual plane through the lamina papyracea, and we describe the principles of a surgical technique that facilitates removal of such tumors.

METHODS

We performed a retrospective study on 8 patients with symptomatic frontal sinus osteomas, including tumors extending past the commonly recognized limits of endoscopic resection because of their size or site of attachment.

RESULTS

All tumors were removed by a purely transnasal endoscopic approach. No major complications were observed during or after the operation. All patients experienced improvement or total regression of their symptoms.

CONCLUSIONS

With appropriate instruments and specific endoscopic techniques, it is possible to resect osteomas that not long ago were deemed inaccessible to endoscopic surgeons. The commonly recognized limits of endoscopic treatment of such tumors may be exceeded in some cases; however, favorable anatomic conditions are decisive for a successful operation.

[Cathepsin D activity in chronic rhinosinusitis with nasal polyps]

Nasal polyposis affects about 1 to 4% of the population. Polyps develop in oedematous and inflammated mucous membrane. In spite of the intensive research the pathomechanism of their development is not fully understood. The majority of the theories concerning the development of nasal polyps emphasize the role of the inflammatory process causing the rupture of the epithelium and the basal membrane. Cathepsin D is one of important mediators of inflammatory processes, that may be involved in the pathogenesis of nasal polyposis.

THE AIM OF THE STUDY

was to establish the role of the cathepsin D in the pathogenesis of nasal polyps. MATHERIAL AND METHOD: Tissues were taken from 39 patients treated with endoscopic sinus surgery due to chronic rhinosinusitis with polyps. The activity of the cathepsin D was assesed with spectrofotometric method using the specific inhibitor (pepstatin) in tissue of nasal polyps, in oedematous and the inflammated mucous membrane of the nasal conchae and the samples of mucous membrane taken from the nasal septum.

RESULTS

Statistically significant difference in cathepsin D activity between polypoid tissue, inflammated mucosa and the mucous membrane of the nasal septum was detected (t-student test, p < 0.05). No difference in the activity of this enzyme was observed between the polypoid tissue and the inflammated mucosa.

CONCLUSION

Increased activity of the cathepsin D in nasal polyps and inflammatory changed mucosa confirm the important role of the cathepsin D in inflammatory processes leading to damage and subsequent remodeling of mucous membrane. We believe that further research on the activity of other proteolytic enzymes is necessary to demonstrate the differences between the inflammable changed mucous membrane and nasal polyps.

[Reduction of intraoperative bleeding during functional endoscopic sinus surgery]

Functional endoscopic sinus surgery (FESS) is a surgical procedure, during which all necessary manipulations are performed while using a fibreoptic camera. The endoscope is inserted together with the surgical instruments, through the nasal cavity. During the surgery, bleeding has to be minimized, since even a small amount of blood may completely obstruct vision via the endoscope. Various approaches have been used to secure a dry operating field; among them are: topical vasoconstrictors, Fowler's position, alpha-and beta-adrenergic blockade, and preoperative steroids. All these methods are far from being effective and are associated with significant side effects. The recently approved approach to this problem is to combine total intravenous anaesthesia using propofol and remifentanil, together with esmolol. With the heart rate reduced to 60 bpm, excellent operative conditions can be achieved with moderate hypotension (MAP 65 mm Hg-8.7 kPa). Altered microcirculation and a low cardiac output are the principal underlying mechanisms in these cases.

[The influence of endoscopic treatment of isolated, small inflammatory lesions of sphenoid sinus on headache sensation]

One of the most frequent complaint in patients with isolated sphenoiditis is headache. In large proportion of these patients no pathologic findings are revealed in sphenoethmoidal recess endoscopicaly thus discrimination between sinus originated and primary headache in such cases may be especially difficult.

THE AIM OF THIS STUDY

Was the assessment of the influence of endoscopic treatment of isolated, small inflammatory sphenoid sinus lesions on headache sensation.

MATERIAL AND METHOD

13 patients suffering from headache, with CT-diagnosed isolated, small inflammatory lesions of sphenoid sinus such as mucosal thickening, polypoid tissue and cysts were treated endoscopicaly. Headache was assessed on the basis of five-grade scale before surgery, 1 month after surgery and after the observation period that varied between 5 to 40 months.

RESULTS

In the first postoperative month the improvement in their headache was declared by 84.6% of patients, but after longer observation the success rate lowered to 61.5%. The improvement was observed both in patient whose the only complaint was headache and in patients with negative endoscopic findings.

CONCLUSIONS

Small isolated sphenoid sinus lesions constitute a group of specific pathologies of paranasal sinuses, which is still difficult to diagnose despite of technological advancement. The treatment of these lesions remains controversial. Decision as to operative treatment should be taken cautiously since headache in great proportion of these patient is not sinus originated. Further multicenter studies on the basis of larger group of patients are necessary to delineate the indications for surgical intervention in patients with small isolated inflammatory sphenoid sinus lesions.

[Fungal infections of the paranasal sinuses treated by endoscopic sinus surgery in material of Otolaryngology Department of Medical University in Białystok]

Over the last years we have observed a high frequency of fungal infections of the paranasal sinuses. Fungal infections can be grouped into invasive and non-invasive forms. Surgical removal of the sinus fungal masses to ensure drainage and aeration is performed using the endoscopic sinus surgery. General or local antifungal drugs are not indicated in the cases of non-invasive forms. For the treatment of invasive fungal sinusitis aggressive antifungal therapy and surgical treatment are the mainstays of management. The treatment results of 18 patients suffering from fungal infections of the paranasal sinuses operated endoscopically during 4 years period (2006-2009) in Otolaryngology Department of Medical University in Białystok were presented.

[Assessment of olfactory disturbances in the patients with rhinosinusitis and polypi nasi treated by endoscopic sinus surgery]

One of the most common symptoms of chronic rhinosinusitis with polyps is smell deterioration. Polypectomy and mechanical restoration of patency of the nose not always and not to the same degree leads to the sense of smell improvement. THE AIM OF STUDY was to assess the sense of smell and nasal patency in patients with chronic rhinosinusitis with polyps treated endoscopically during the healing period and the process of functional normalization of the nasal mucosa.

MATERIAL AND METHODS

30 patients suffering from chronic rhinosinusitis with polyps treated endoscopically were included in the study. Nasal resistance (anterior rhinomanometry), smell (smell threshold and identification tests) and rhinoscopic findings were assessed and analyzed 1, 3, 6 and 12 months postoperatively.

RESULTS

The most conspicuous decrease of mean nasal resistance was observed in the first control examination (1 month postoperatively) and then further slight improvement continued until sixth postoperative month. Restoration of the patency of the nose yielded only inconsiderable improvement of smell in first postoperative month. Significant improvement of smell could be detected as late as in third and sixth month after the operation. In the twelfth postoperative month slight deterioration of the mean results of smell and nasal patency tests was noted. At the same time control endoscopic examination revealed recurrent polyposis in 26.6% of patients whereas the improvement in mean smell test result in comparison to preoperative results was observed in over 66.6% of patients.

CONCLUSIONS

The smell improvement in patients with rhinosinusitis with polyps after endoscopic surgery occurs later than the nasal patency improvement what may be attributed to the process of healing and functional normalization of the nasal mucosa. On average after a year in some patients first clinical symptoms of recurrent disease emerges. Taking in to the consideration chronic and complex nature of the disease it seems reasonable to assess nasal resistance and smell during longer follow up period.

[Endoscopic management of cerebrospinal fluid rhinorhea]

Endoscopic surgery due to its high efficacy and relatively minor intraoperative trauma became a standard of transnasal csf leak treatment.

THE AIM OF THIS STUDY

was to present, basing on our own experience, diagnostic and therapeutic methods of treatment of various types of csf rhinorhea.

MATERIAL AND METHOD

All together 14 endoscopic skull base reconstructions were performed. The bony defect and dural perforations were closed using: fat grafts, septal bone or cartilage, mucosal flaps of the septum or nasal concha, artificial dura and collagen sponge with fibrin glue. The defect was localized by high resolution computed tomography, magnetic resonance cisternography, neuronavigation system and fluorecein test.

RESULTS

Complete closure of the defect and resolution of the csf leak after the first attempt was achieved in 92,3% of patients. In one case the rhinorhea was successfully stopped after the second reconstructive procedure. No adverse reaction of intrathecal fluorescein administration were noted in our patients.

CONCLUSIONS

Endoscopic surgeons have a wide variety of diagnostic tools and operative techniques at their disposal for precise localization and management of csf rhinorhea. The key for high efficacy of the treatment is appropriate selection of diagnostic and surgical method depending on cause, type, size and localization of the leak.

[Endoscopic surgery of the orbit]

Thanks to continuous improvement of instrumentarium, methods of imaging and intraoperative neuronavigation, endoscopic techniques are increasingly used for management of intraorbital pathologies. The aim of the study was to present, basing on own experience, the virtues and limitations of endoscopic transnasal surgery in the diagnosis and treatment of orbital pathologies. This article contains a review of endoscopic treatment of lacrimal duct stenosis, evacuation of inflammatory lesions and benign tumors penetrating the orbit from the adjacent sinuses, management of primary intraorbital tumors, Graves-Basedov orbitopathy and posttraumatic lesions of the optic nerves. Both own experience and data from the relevant literature indicate that intraorbital inflammatory lesions can nowadays be effectively treated by means of endoscopy whereas purely endoscopic removal of intraorbital tumor still remains rare because is technically demanding and requires high experience in this type of surgery. In case of malignancies endoscopy may be used for diagnostic purposes and/or as a method supporting conventional external surgical approaches.

[Neuronavigation in transnasal endoscopic paranasal sinuses and cranial base surgery: comparison of the optical and electromagnetic systems]

Transnasal endoscopic operative methods became increasingly popular in paranasal sinuses and cranial base surgery. Various types of localization systems are recently used to navigate through and between tangled anatomical structures in this region. The aim of this study was to compare (as basing on our own clinical experience), the advantages and limitations of the optical and electromagnetic neuronavigation systems.

MATERIAL AND METHOD

Optical neuronavigation system (Stealth Station Treon plus, Medtronic, U.S.A.) and electromagnetic neuronavigation systems (DigiPointeur, Collin, France and Fusion ENT, Medtronic, USA) were used during endoscopic operations of paranasal sinuses, anterior skull base, orbits, parasellar region and clivus. The subject of comparison were precision of both system types and additional time necessary for setting up the system. Also assessed were convenience of navigation and easiness of manipulation with neuronavigated instruments during surgical procedures performed using classical endoscopic technique, bimanual technique and four hand technique.

RESULTS

The accuracy was high and comparable for both system types and did not deteriorate during the procedure. The time needed to set up of the optical system was somewhat longer. Surgeon's comfort during operative procedures was assessed as slightly higher for the electromagnetic systems, especially if four hand or bimanual techniques were used and if constant neuronavigation was indispensible. The optical system allows for navigation of a variety of surgical tools and this was considered a great advantage over the electromagnetic systems in this particular application.

CONCLUSIONS

The additional time spent in the operative theatre for getting a system ready is well paid off by better orientation of a surgeon in the operative field consequently increasing safety and higher accuracy of surgical procedure. What system should a surgeon use depends to a great extent on the type of planed procedure and preferred surgical technique.

[Possible involvement of hexosaminidase in vocal polyps--preliminary report]

Vocal fold polyp is usually a result of the injury of the vocal cords. It often appears after vocal overuse or misuse causing trauma in vocal fold mid-membranous and wound formation. THE AIM OF THE STUDY was to assess the activity of hexosaminidase in vocal fold polyps in the comparison to the control tissue.

MATERIAL AND METHODS

Vocal polyps (n=8) were collected from 8 patients during direct laryngoscopy. Specimens of normal vocal folds were obtained from 8 cadavers (n=8) served as controls. Specimens were immediately frozen in -80 degrees C. To assess hexosaminidase activity, release of p-nitrophenol from p-nitrophenol derivatives was used.

RESULTS

We observed statistical differences between the activity of investigated enzyme in all vocal folds specimens compared with that in normal tissue homogenates. However the activity of HEX achieved a low level. Mean release of HEX from the activated cells in vocal fold specimens was 1.073 nkat/g wet tissue compared with 0.766 nkat/g wet tissue in normal cadaveric vocal fold homogenates.

CONCLUSIONS

Low activity of HEX in vocal fold polyps suggests that inflammation may not be a primary factor in the development of the disease and other mechanism should likely be considered in the pathogenesis of vocal fold polyps.

[The evaluation of olfactory dysfunction after the operation of ruptured anterior communicating artery aneurysm]

Although the frequency of smell disorders after the operations of the anterior communicating artery aneurysm depends to a large degree on the used surgical approach, several independent of surgery factors may contribute to the postoperative smell tests outcome. THE AIM OF OUR STUDIES: The evaluation of the sense of smell in patients who underwent the operation of ruptured anterior communicating artery aneurysm using pterional approach.

MATERIAL AND METHODS

In the retrospective studies the results of smell test of the group of 21 patients operated for ruptured anterior communicating artery aneurysm and 21 healthy volunteers of control group were compared. The patients suffering from neurodegenerative, metabolic and endocrynological disorders, as well as those with rhinoscopic symptoms of rhinosinusitis and with decreased nasal potency confirmed by anterior rhinomanometry were excluded from the study.

RESULTS

During the operations it was possible to anatomically retain olfactory nerves in all operated patients. Severe smell disorders (severe hyposmia and anosmia) were detected in 1 (4.7%) patient of the control group and in 6 (28.5%) patients of postoperative group. The mean composite olfactory score in Cain test of the postoperative group was 4.53, and in the control group 5.47 points. The difference did not reach statistic significance (Mann-Whitney test, p = 0.068).

CONCLUSIONS

Although pterional approach to anterior communicating artery is relatively low traumatic to olfactory tract, the subarachnoid hemorrhage may have an unfavorable effect on postoperative olfactory nerve functioning. Considering the fact, that in spite of thorough examination of the patients, we were not able to exclude from the studied groups all the patients with preoperatively impaired smell, it seems reasonable to perform similar smell test studies in the prospective way.

[Modern neurosurgical techniques to remove intraorbital foreign bodies--report of two cases]

To indicate the usefulness of modern neurosurgical techniques to remove intraorbital foreign bodies, not removed during primary ophthalmological surgical intervention. PATIENT 1: A 29-year-old man, struck with a bottle, with a piece of glass located at the top of the right orbit. During the primary ophthalmological intervention--orbitotomy accessed through the conjunctiva of the fornix of the upper eyelid and the second cut through the wound in the eyelid--the foreign body was not removed. The patient was moved to the Department of Neurosurgery, where 3 days after the injury the 30 mm x 7 mm piece of glass was successfully removed with the aid of neuronavigation system. The surgical approach was through a cut in the right eyebrow and the foreign body was found to be located in the back-top part of the orbit. PATIENT 2: A 30-year-old man, hit with a piece of wood, with an organic foreign body (wood), located in the mid-lower and medial part of the right orbit. During the primary ophthalmological operation--orbitotomy accessed through the conjunctiva of the fornix of the lower eyelid--the foreign body was not removed. The patient was moved to the Department of Neurosurgery, where the surgeon unsuccesfuly attempted to remove the foreign body through the wound in the conjunctiva of the fornix of the lower eyelid with the aid of neuronavigation. In this situation the endoscopic technique with access through the nose was used. The mid part of the medial orbit wall was removed and partially fragmented piece of wood was located with the use of the neuronavigation. The foreign body was located in the middle part of the orbit, near the medial wall. It was removed in four pieces measuring: 8 mm x 3 mm, 8 mm x 4 mm, 15 mm x 5 mm, 18 mm x 6 mm.

[CO2 laser treatment of rhinophyma]

Treatment of the advanced form of rhinophyma causing severe nasal deformity and nasal breathing impairment is reserved mainly for surgical methods. Laser techniques among them play particular role. The aim of the study was to present short series of patients suffering from severe form of rhinophyma, who were treated with CO2 laser, emphasizing the advantages and disadvantages of the method used.

MATERIAL AND METHOD

Three male patients, aged 51-69, with advanced form of rhinophyma were treated in our clinic with CO2 laser. The total removal of pathologic tissue was performed during 2-3 sessions of laser therapy with an interval 4-8 weeks in-between.

RESULTS

The follow-up ranged from 4-12 months. Satisfactory cosmetic and functional result was achieved in all patients. Full reepithelization of the wound took place within 4-6 weeks. Intensive bleeding from dilated vessels during the procedure that required bipolar electrocautery occurred in two cases. There were no postoperative complication in the studied group.

CONCLUSIONS

The CO2 laser is relatively save and precise surgical tool for rhinophyma ablation. If the resection is not to aggressive, healing process is quick and without excessive scaring. Unfortunately the "dry field" conditions are not always possible to achieve during operation, due to limited coagulative properties of the CO2 laser towards dilated blood vessels. In advanced stages of rhinophyma to increase safety of the procedure, several sessions of the laser therapy might be necessary to remove all the hypertrophic tissue.

[Selected applications of diode laser in laryngological surgery]

Diode laser due to emitted wavelength and achieved tissue effect appear to be universal tool for broad range of applications in laryngological surgery. The aim of the study was to present variety of applications of this type of laser in the treatment of selected pathologies of the nose, pharynx and oral cavity.

MATERIAL AND METHOD

45 patients with various pathologies of the nose, pharynx and oral cavity were subjected to diode laser treatment under control of endoscopes and video routing system. In the studied group diode laser was used for hyperplastic turbinates treatment, correction of concha bullosa and septum deformations, ablation of nasal polyps and synechiae inside nasal cavity including cicatrical stenoses in the orifice of common lacrimal canalliculus, coagulation of vascular hemorrhagic diathesis, ablation of bleeding granulomas and polyps and treatment of vascular malformations. Results. Endoscopic diode laser surgery enabled for precise and save removal of the pathology accompanied only by minimal intraoperative bleeding. Healing and reepithelization process were normal and even in large postoperative defects do not exceeded 12 weeks. Postoperative complications in the form of cicatrix and synechiae were found in 3 patients.

CONCLUSIONS

Various pathologies may be treated effectively with diode laser if appropriate laser beam parameters and surgical technique is applied.

[Endoscopic dacryocystorhinostomy in patients with postsaccal stenosis of lacrimal duct]

Dynamic development of the endoscopic treatment of the lacrimal duct obstruction has been observed for the last 20 years. Various causes of the tear outflow disorders, different levels of lacrlmal duct blockage may require different surgical approach and sometimes additional modern equipment. THE AIM of the study was to present the results of treatment of possibly uniform group of patients with lacrimal duct obstruction in whom the same method of endoscopic surgery was applied.

MATERIAL AND METHOD

16 patients with postsuccal level of obstruction were qualified for the study. All of them were treated endoscopically with mucosal flap formation. Patients in whom synechiae in the upper part of the sac or at the orifice of common canalicullus were found during the procedure were excluded from the study, as well as the patients with Wagener's granulomatosis and posttraumatic form of lacrimal obstruction.

RESULTS

Release of epiphora and proper patency of lacrimal system corroborated by irrigation test was achieved in 14 (87,5%) patients of the studied group. In 2 (12,5%) patients recurrence of symptoms was observed. In both cases too small osteotomy and lack of surgical technique precision were the cause of failure. No major complications in the studied group were observed.

CONCLUSIONS

Endoscopic dcryocystorhinostomy Is low traumatic and effective procedure of surgical treatment of lacrimal duct obstruction. The success is determined by high precision of surgical technique.

[Endoscopic transnasal approach for optic nerve decompression]

Optic nerve decompression is nowadays increasingly performed using endoscopic technique. THE AIM of this report is to present a clinical series of 8 patients operated on with this technique due to posttraumatic loss of vision and other visual disturbances. Technical details of this procedure and surgical anatomy will also be discussed.

MATERIAL AND METHODS

Endoscopic optic nerve decompression was performed in eight patients using transnasal transethmoidal approach. The loss of vision was caused by posttraumatic optic neuropathy in 6 patients, optic neuritis in 1 patient and by cystic lesion of the orbital apex and sphenoid sinus in 1 patient.

RESULTS

Vision acuity improvement was achieved in 4 patients (50%). Complications included intraoperative cerebrospinal fluid leak occurred in 2 patients. In one of them the leak had to be sealed using intracranial approach.

CONCLUSIONS

Endoscopic optic nerve decompression can be used in appropriately selected patients with optic nerve lesions to improve the visual functions. High technical skill, proper endowment and thorough knowledge of surgical anatomy are prerequisites of success. Good interdisciplinary cooperation between the laryngologist and neurosurgeon helps in minimizing the risk of serious complications, especially in posttraumatic cases.

[Endoscopic decompression of the optic nerve in patients with post-traumatic vision impairment]

PURPOSE

Traumatic optic neuropathy (TON) is a dangerous complication of head trauma but the mechanism of the symptoms still remains obscure. Moreover, there is no uniformly accepted treatment protocol for this condition. Endoscopic, minimally invasive decompression of the optic nerve in its bony canal is an alternative to conservative approach.

MATERIAL AND METHODS

Endoscopic optic nerve decompression was performed in 6 patients, whom head trauma caused blindness or severe impairment of vision. In 5 of them direct optic nerve injury might have been suspected due to presence of bony fractures in the region of the optic canal and the orbital apex. The time from the trauma to the surgical intervention varied from 8 hours to 30 days. All the patients before the attempted surgery were treated with steroids, however the doses and time of this treatment varied significantly.

RESULTS

There were no complications of the surgery; all the patients were mobilized on the day of operation and reported no problems with nasal breathing. Vision improved in 2 of 6 patients (33.3%), interestingly both of them had experienced rather gradually developing deterioration of vision during several hours after the trauma.

CONCLUSIONS

Endoscopic optic nerve decompression is a minimally invasive and safe procedure to be employed for optic nerve decompression in patients with posttraumatic impairment of vision.

[The evaluation of the effectiveness of uvulopalatopharyngoplasy in the treatment of selected patients with mild to moderate obstructive sleep apnoea--one year of postoperative follow up]

The uvulopalatopharyngoplasty (UPPP) is one the most commonly used surgical procedure for the treatment of obstructive sleep apnoea (OSA) patients. The effectiveness of this procedure in a group of unselected patients is estimated on about 40%.

AIM OF THE STUDY

To assess the efficacy of uvulopalatopharyngoplasty in the treatment of mild and moderate OSA patients, qualified for the study by simple clinical criteria, one year after UPPP. One year postoperative results were also compared with the early results obtained 4-6 months postoperatively.

MATERIAL AND METHODS

20 patients who meet the following criteria: respiratory disturbance index RDI <30, body mass index BMI<30, collar size <43 cm, tongue size - I and II grade in modified Mallampati scale were qualified for the study. The first examination of breathing disturbances during sleep was performed 4-6 months after the operation and the second after 12 to 14 months of follow up.

RESULTS

The first control examination revealed at least 50% reduction of RDI in 75% of patients, and RDI dropped below 10 in 60%. One year postoperatively the reduction of RDI by at last 50% was maintained in 60% of patients, and RDI dropped below 10 in 40% of cases. The mean RDI decreased from 21.35 preoperatively to 9.85 in the first control examination and subsequently slightly increased to 10.25 after one year of follow up.

CONCLUSIONS

Application of simple clinical criteria to patients' qualification for UPPP slightly improved the effectiveness of this type of surgical procedure. Regular control examinations of breathing disorders during sleep seem to be necessary, due to possible deterioration of the early postoperative results, in order to detect therapeutic failure and eventually apply other form of treatment.

[The assessment of nasal surgery and uvulopalatopharyngoplasy (UPPP) in the treatment of patients with mild and moderate obstructive sleep apnea (OSA)]

The role of nasal patency in the pathogenesis of OSA is not fully understood. There are conflicting data in the literature considering the influence of the nasal resistance on RDI. The aim of the study was to assess if the surgical procedures aimed at increasing nasal patency performed simultaneously with UPPP (uvulopalatopharyngoplasty) may improve it's effectiveness.

MATERIAL AND METHODS

20 patients with mild to moderate OSA (RDI < 30) were qualified for the study. Their BMI was less than 30, and total nasal resistance assessed by anterior rhinomanometry exceeded 0,45 kPa/l/s in each patient. The UPPP and nasal surgery (septoplasty, mucoplasty or CO2 laser mucotomy) were performed as a one surgical procedure in all patients.

RESULTS

The effectiveness of simultaneously performed UPPP and nasal surgery reached 55% in the group of unselected mild to moderate OSA patients. Snoring volume decreased to the level that did not disturb sleep of others in 75% of patients.

CONCLUSIONS

Nasal surgery minimally increased the effectiveness of UPPP in the treatment of unselected mild to moderate OSA patients. These surgical procedures caused noticeable decrease of snoring volume that was corroborated both subjectively and objectively. At the same time snoring was more reduced than RDI in studied group of patients.

Ocena przydatności pomiarów cefalometrycznych w diagnostyce pacjentów z obturacyjnym zespołem snu z bezdechami – doniesienie wstępne

INTRODUCTION

The pathophysiology of OSAS is related with local anatomical predispositions to OSA such as craniofacial anomalies, adenoid and tonsillar hypertrophy, macroglossia, hypertonic oropharyngeal soft tissue, base of tongue proptosis, mandibular hypoplasia, posterior mandibular displacement, maxillary retrusion, enlarged uvula, retrognathia, and inferior positioning of the hyoid. The AIM of the study was to evaluate the usefulness of cephalometric measurements in patients with obstructive sleep apnea syndrome (OSAS).

MATERIAL AND METHODS

Eighteen randomly selected patients with snoring and varying degrees of sleep-disordered breathing were included in this study. All patients underwent completed otolaryngological examination, somnographic test using Poly-Mesam device, cephalometric radiographs and craniofacial CT scans. A control group had the same examinations and cephalometric tests. These patients had no snoring or clinical evidence of sleep-disordered breathing. No patients had prior pharyngeal or maxillomandibular surgery. Lateral cephalometric radiographs were obtained on all subjects in standing position using a standard technique. Each subject had also an awake CT scan in supine position on the back.

RESULTS

According all parameters we gathered from the study, OSAS is associated with significant changes in cephalometric measurements. Cephalometric analysis adds further information regarding the anatomical assessment of OSAS patients however we found craniofacial CT scans easier, more accurate measurements especially applying to soft tissues.

Neuroendocrine cells in the nasal mucosa - preliminary report

The role of neuroendocrine cells (NC) in physiology and pathology of the human's respiratory tract is not fully understood. The aim of the study was the quantitative and morphometric assessment of NC in nasal mucosa in some pathological states.

PATIENTS AND METHOD

40 patients, aged 28-63 years, with clinical signs of chronic, hypertrophic rhinosinusitis were qualified for the study. Rhinitis chronica hypertrophica coexisted with aspirin triad or asthma in 10 patients (group I), with advanced obstructive sleep apnea syndrome (OSAS) in 10 patients (respiratory disturbance index, RDI>40, group II). Group III consisted of 10 patients with simple rhinitis chronica hypertrophica who habitually smoked cigarettes (at least 20 cigarettes a day) while 10 non-smoking patients with simple rhinitis chronica hypertrophica were qualified to the control group. Fragments of nasal mucosa of approximately 0.5 cm(2) were collected from medial or inferior turbinate during mucoplasty procedures. NC were detected immunohistochemically using antibodies against chromogranin A (DAKO). The microscopic sections were evaluated in the light microscopy.

RESULTS

The study did not reveal the increased number of NC in examined fragments of nasal mucosa. Scattered NC were detected in single preparations of nasal mucous membrane in some patients in all groups. The number of detected neuroendocrine cells did not differ statistically between groups.

[Assessment of the effectiveness of uvulopalatopharyngoplasty (UPPP) in the treatment of mild and moderate OSA patients preliminarily selected for the procedure by simple clinical examination]

INTRODUCTION

There is abundant conflicting information in the literature about prognostic value of sophisticated, diagnostic tests as well as data from simple clinical examination in its surgical treatment due to the complex nature of OSA. The aim of our study was to assess the efficacy of uvulopalatopharyngoplasty in the treatment of mild and moderate OSA patients who were preliminary selected by simple clinical examination.

MATERIAL AND METHOD

20 patients with obstructive sleep apnea syndrome were included in this study. There were patients who met the following criteria: RDI less than 30, BMI less than 30, collar size less than 43 cm, normal nasal potency, modified Mallampati grade I or II, were enrolled in the study. The mean age of the patients was 45,5. Modified Mallampati score was used for evaluation the structures of oropharynx.

RESULTS

55% of patients were classified for grade I in Mallampati score and 45% of patients- grade II in this scale. At least 50% reduction of RDI after UPPP was observed in 75% of patients. The mean RDI was decreased from 21,35 in preoperative period to 9,85 in the control study. In 60% of our patients the RDI dropped to the value of less then 10. In 5% of the patients, the surgical treatment did not decrease at least 50% of RDI. However in this patient group, we observed a slight improvement of mean minimal saturation (from 84,1 +/- 3,8 to 86,2% +/- 3,6).

CONCLUSION

Using simple clinical parameters for preliminary selection of patients with mild and moderate OSA enabled us to achieve considerably better success rate after UPPP.

[Cystic fibrosis (CF) of adults--current problem of laryngologists. The role of genetic research]

INTRODUCTION

The goal of this work is to evaluate DNA in the direction of gene mutation in the patients with nasal polyps and/or recurring inflammation of the sinuses, and who tested negative for allergic basis of those ailments.

MATERIAL AND METHODS

50 patients aged 20-45 have been included in the research by the University Hospital and the Laryngological Outpatient Clinic SPSK in Białystok. The patients had symptoms of nasal polyps and recurring inflammation of the sinuses. The analysis of DNA samples of the blood according to the PCR method using the ABI Prism 3100 device and testing for finding mutations of cystic fibrosis--The Cystic Fibrosis Assay.

RESULTS

We discovered 1 mutation of delta F508 in a 40-year-old patient, with recurring inflammation of nasal sinuses (described in the case of this patient).

CONCLUSIONS

The DNA research method can be used for discovering atypical forms of CF in patients with recurring symptoms of the inflammation of the sinuses and nasal polyps, and who tested negative for allergic basis of those ailments. A wide routine screening in the direction of the mutation of CF may lead to an explanation the reason of the nasal polyps and inflammation of the sinuses.

[Early results of the treatment of chronic sinusitis with functional endoscopic sinus surgery]

In recent years FESS has become a gold standard in the treatment of chronic sinusitis. The results of the treatment depends to a high degree on the thorough preoperative assessment and qualification for surgery, as well as applied criteria reported for success. The aim of the study was to evaluate the early results of FESS in patient with chronic sinusitis after 3 to 12 month of follow up focusing attention on some prognostic factors. In the group 52 patients who underwent FESS in 2003 due to chronic sinusitis particular attention to standardization of pre and postoperative evaluation was paid. Meticulous analysis of the data from SNAQ 11 (sino nasal assessment questionnaire) questionnaire for subjective complaints evaluation, and assessment of the extent of disease according to Friedman, Kennedy and Levine scale revealed no correlation between extent of disease and results of treatment. It was demonstrated, that there is the statistically significant correlation between extent of sinus disease on CT scans and the duration of disease. It applies to the first tree years of disease.

Loss of heterozygosity in laryngeal cancer

PURPOSE

Head and neck cancers account for about 6% of all human cancers. Molecular changes leading to the disease development and progression still remain not fully explained. Examination of loss of heterozygosity (allelic loss, LOH) using the specific microsatellite markers is a method of choice in assessing tumour suppressor genes (TSGs) localisation in human genome.

MATERIAL AND METHODS

The study was performed in a group of 46 male patients, aged 42-77 years. Forty three patients underwent total laryngectomy with lymph nodectomy, two patients--chordectomy and one patient--partial laryngectomy. Tumour tissue specimens and reference peripheral blood samples were obtained during surgical resections. Standard methods were used for DNA isolation. Fluorescent multiplex PCR was used to amplify microsatellite loci included in commercially available human identification kits.

RESULTS

LOH was found at the following loci: BAT26, D3S1358, FGA, CSF1PO, D5S818, D8S1179, VWA, D13S317, D18S51. The highest LOH frequency was found in the tumor samples where the neighbouring cervical lymph nodes were affected but the incidence of LOH at BAT26 was statistically insignificant (p = 0.07).

CONCLUSIONS

High incidence of LOH is considered an unfavourable prognostic factor accompanying an aggressive nature of the tumour and indicating an involvement of certain genome regions in cancerogenesis. In head and neck cancers LOH was found on the following chromosomes: 3p, 5q, 8p, 9p, 9q, 11q, 17p, 17q, 18p, 18q.

[Some aspects of pharmacotherapy of tinnitus. Compound therapy with Xylocaine and directive counseling--long-term results]

29 out of 49 patients, who were treated in 1996-1998 with Xylocaine and directive counselling for their tinitus, were reevaluated. Non of the patients used any other pharmacological treatment of the tinnitus or underwent full tinnitus retraining therapy (TRT) since 10-days treatment with Xylocaine had been completed. Initially 65.3% of patients declared improvement in their tinnitus. After over 5 years of observation success rate decreased to only 41.3%. Since the positive effect of 10-days treatment with Xylocaine and directive counselling was not stable we concluded that tinnitus patients should receive full TRT.

[2% solution of vagothyl in the treatment of persistent otorrhea]

Drying of the ear in the chronic purulent otitis media prevents further lesions of the anatomic structures and allows for performing the surgery significantly decreasing the risk of any potential complications. In the search for a safe medicines that can be used for drying of the ear in persistent otorrhoea the examinations on vagothyl have been conducted. The aim of this work was to assess the outcome of treating of persistent otorrhoeas with 2% solution of vagothyl. The results were compared to those achieved when 4% vagothyl's solution was applied. The effects of the treatment with both strengths of the vagothyl's solution were similar. In case of usage of 2% solution of vagothyl there were fewer side effects. The method of treatment was modified in order to eliminate the possibility of occurring of the iatrogenic lesions.

[Management of lymph node metastases in larynx surgery with organ preservation]

The method of lymph node metastases management in sparing larynx surgery is presented. Described method consist in simultaneous, bilateral lymphadenectomy, as suggested by Bocca, and partial larynx resection. The effectiveness of the above treatment was evaluated in the group of 85 patients suffering glottic and supraglottic planoepithelial carcinoma. In this series, in 22 cases nodal metastases were histologically confirmed. In 6 patients bilateral nodal metastases were found. In any case the radiation therapy was introduced, because postradiation tissue reaction destroy functional principles of the operation. During several months of follow up in only 3 cases nodal recurrence was detected. The evaluation of treatment outcome proved that bilateral lymphadenectomy, as suggested by Bocca, is highly effective in management of lymph node metastases.

[Transient evoked otoacoustic emissions (TEOAE) in tinnitus patients treated with xylocaine]

The group of patients suffering from tinnitus was treated with intravenous Xylocaine. Ten consecutive doses of Xylocaine (2 mg/kg b.m.) were administered during a period of ten days. Changes of amplitudes of TEOAE in relation to tinnitus suppression was assessed. In 91.5% of cases we observed correlation between amplitude changes and complaint abatement. Both amplitude changes and the time of tinnitus suppression increased after ten days of treatment in comparison with single dose of Xylocaine. The differences of amplitude variations between tinnitus and non tinnitus ear group was statistically significant (Wilcoxon test p < 0.05). The treatment with Xylocaine was considered to be the beginning of long-term procedure aimed at causing habituation of tinnitus in patients conscience (TRT).