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Histologic correlation of VEGF and COX-2 expression with tumor size in squamous cell carcinoma of the larynx and hypopharynx

April 30, 2017  |  Rodrigo Gonzalez Bonhin, MD; Guilherme Machado de Carvalho, MD; Alexandre Caixeta Guimaraes, MD; Vanessa Brito Campoy Rocha, MD; Carlos Takahiro Chone, MD, PhD; Agrício Nubiato Crespo, MD, PhD; Eliane Maria Ingrid Amstalden, MD, PhD


The prognosis and survival of patients with laryngeal and hypopharyngeal squamous cell carcinoma (SCC) are related to the clinical staging. Tumor growth and metastasis are closely related to angiogenesis. Vascular endothelial growth factor (VEGF) and cyclooxygenase 2 (COX-2) are intimately related to the angiogenic process in which the blood supply required for neoplastic evolution is ensured. Considering the contributions of VEGF and COX-2 to the formation, growth, and progression of primary tumors, as well as their metastasis, it has been thought that the expression of these two factors might be related to the size and/or aggressiveness of laryngeal and hypopharyngeal cancer. To test that theory, we conducted a retrospective study to evaluate the expression of VEGF and COX-2 markers in archived specimens of SCC of the larynx and hypopharynx to correlate their expression with tumor size. These specimens had been obtained from 35 patients-31 men and 4 women, aged 37 to 75 years (mean: 57)-who had been treated for laryngeal or hypopharyngeal SCC at our tertiary care university hospital over a period of 15 years. Immunohistochemical analyses were performed with avidin-biotin-peroxidase staining for VEGF and COX-2 antibodies. The degree of VEGF and COX-2 expression was based on the German scale of immunoreactivity. Specimens were separated into groups based on the intensity of expression (none/low and moderate/strong) and tumor size (TNM categories T1/T2 and T3/T4). A total of 7 patients exhibited moderate or strong VEGF expression (3 from the T1/T2 group and 4 from the T3/T4 group), and 17 patients demonstrated moderate or strong COX-2 expression (8 from the T1/T2 group and 9 from the T3/T4 group). We found no statistically significant relationship between tumor size and either VEGF or COX-2 expression. Our study demonstrated that despite the intrinsic connection between and VEGF and COX-2, neither appears to be related to the size of the SCCs of the larynx or hypopharynx. Other factors must be involved in the pathogenesis and progression of this disease, and further studies are needed to identify them.

Role of intraoperative ropivacaine in adult post-tonsillectomy pain control: A randomized controlled trial

April 30, 2017  |  William C. Yao, MD; Christian A. Corbitt, MD; Masayoshi Takashima, MD


We sought to evaluate the efficacy of ropivacaine in post-tonsillectomy pain management in adults and evaluate the timing of intraoperative ropivacaine administration for this purpose. A prospective, double-blinded, randomized, controlled trial with a paired design was performed in 25 consecutive adults undergoing tonsillectomy. To date, no studies examining the efficacy of local anesthetics in post-tonsillectomy pain control have used a paired design to account for the variability in pain difference between individuals. Patients were prerandomized into those receiving tonsillar fossa injections before or after the tonsillectomy. All surgeries were performed by the senior author. The tonsil on 1 side was injected with saline and the tonsil on the other side with ropivacaine. Patient responses were obtained via written questionnaire. Three of 25 patients were excluded from the study. Sixteen of 22 patients had lateralization of pain to 1 side during recovery. No statistically significant difference in pain control was observed between ropivacaine and normal saline. Local anesthetic decreased pain in 7 of 22 patients, and increased pain was experienced on the side with local anesthetic in 9 of 22 patients. Six of 22 patients had no difference in pain from one side to the other. The time to equalization of pain based on laterality was 8.8 and 6.8 days, respectively, in the patients injected before or immediately after the tonsillectomy. Administration of the local anesthetic ropivacaine does not affect post-tonsillectomy pain. Moreover, timing of injection does not affect postoperative pain. We recommend against the use of intraoperative ropivacaine for pain control in patients undergoing tonsillectomy.

Atypical presentation of vocal fold granulomas

April 30, 2017  |  Raj B. Patel, MD; Aaron Jaworek, MD; Robert T. Sataloff, MD, DMA, FACS

Vocal fold granulomas usually form near the vocal process or on the mucosa covering the medial surface of the arytenoid cartilage. These lesions are not true granulomas and consist of fibroblasts, collagen, leukocytes, and proliferating capillaries.

A huge parapharyngeal space tumor in a child

April 30, 2017  |  Yuntsung Hung, MD; Chi-Shiun Huang, MD; Liang-You Yang, MD

Most clinicians will see only a small number of cases of parapharyngeal space tumors during their careers.

Facial nerve mimicking the fibrocartilaginous annulus of the tympanic membrane

April 30, 2017  |  Hande Senem Deveci, MD; Tülay Erden Habeşoğlu, MD; Cem Karataş, MD; Selami Uzun, MD

In this case, the mastoid segment of the facial nerve was mobilized with a microelevetor at the posterior quadrant, but the facial nerve was preserved.

Endoscopic view of long-term patency of the sphenoid ostium following balloon dilation

April 30, 2017  |  Joseph P. Mirante, MD, MBA, FACS; Dewey A. Christmas, MD; Eiji Yanagisawa, MD, FACS

In this case a 32-year-old patient with a history of recurrent sphenoid sinusitis had undergone balloon dilation of the sphenoid sinus ostium approximately 7 years earlier.

Therapeutic effect of hyaluronic acid in reducing nasal mucosa recovery time after septoplasty

April 30, 2017  |  Francesco Klinger, MD; Fabio Caviggioli, MD; Andrea Vittorio Emanuele Lisa, MD; Luca Maione, MD; Valeriano Vinci, MD; Mattia Siliprandi, MD; Federico Barbera, MD; Marco Klinger, MD; Luca Malvezzi, MD


Mucociliary clearance represents a host defense mechanism of airways that can be compromised by various pathologic conditions, such as nasal septal deviation. Although septoplasty can resolve obstruction, it impairs mucociliary clearance in the immediate postoperative period. Clinical studies have demonstrated how hyaluronic acid can interfere with this function. Our study aims to provide evidence of a therapeutic effect of hyaluronic acid on nasal mucosa recovery after septoplasy. Sixty-five patients underwent septoplasty. On postoperative day 1, patients were randomized to a control arm that was treated with mupirocin ointment or an experimental arm that received additional treatment with sodium hyaluronate solution. Pre- and postoperatively, anterior rhinoscopy was performed to analyze mucosal status, and mucociliary clearance was measured by using the saccharin transit time (STT) method. The t test was used for independent groups. During the preoperative evaluation, we observed a significant difference in STT between the convex and concave side in both groups. Fifteen days after surgery, we observed a significant difference preoperatively to postoperatively for both the convex and the concave side (p < 0.02 and p < 0.008, respectively). One month after surgery, we observed a reduction of STT when comparing preoperative control group values and, after 1 month, postoperative values in both sides (p < 0.015 and p < 0.005, convex and concave side, respectively). Our results show a significant reduction of the STT for both nasal sides as soon as 15 days after septoplasty in patients randomized to additional treatment. Our experience provides further evidence for the therapeutic effect of hyaluronic acid in accelerating nasal mucosa recovery after septoplasty.

In-office vs. operating room procedures for recurrent respiratory papillomatosis

April 30, 2017  |  Anya J. Miller, MD; Glendon M. Gardner, MD


We conducted a study to analyze hospital and patient costs, outcomes, and patient satisfaction among adults undergoing in-office and operating room procedures for the treatment of recurrent respiratory papillomatosis. Our final study population was made up of 17 patients-1 man and 16 women, aged 30 to 86 years (mean: 62). The mean number of in-office laser procedures per patient was 4.2, and the mean interval between procedures was 5.4 months (although 10 patients underwent only 1 office procedure); the mean number of operating room procedures was 13.5, and the mean interval between procedures was 14.3 months. An equal number of patients reported complications or adverse events with the two types of procedures-5 each. The difference in cost between the office procedure (mean: $3,413.00) and the operating room procedure (mean: $12,382.59) was almost $9,000, but these savings were offset by the fact that the office procedures needed to be performed three times as often. Patients reported slightly more anxiety and discomfort during the office procedures and, overall, they appeared to prefer the operating room procedure. We conclude that office procedures are significantly more cost-effective than operating room procedures, but their use may be limited by patient tolerance and the increased frequency of the procedure.

Nasal, pharyngeal, and laryngeal pemphigus vulgaris successfully treated with rituximab

April 30, 2017  |  Naveed Sami, MD


Pemphigus vulgaris is a potentially fatal autoimmune blistering disease that can involve the nasopharyngeal and laryngeal tissues. The disease can be recalcitrant to conventional oral treatments, and treatment alternatives are limited. This retrospective study evaluated the efficacy of rituximab as a rescue agent in 5 patients with recalcitrant pemphigus vulgaris involving nasopharyngeal and laryngeal mucosa. All 5 patients were unresponsive to systemic steroids and at least one conventional oral immunosuppressive agent. The patients received rituximab infusions as a rescue agent because of recalcitrant disease. All 5 patients had a complete clinical response to rituximab and could discontinue systemic steroids and reduce the dosage of their initial immunosuppressive agent. No major adverse reactions were observed or reported with rituximab. Rituximab can be used as an effective rescue agent in the treatment of severe pemphigus vulgaris with nasopharyngeal and laryngeal involvement.


April 30, 2017  |  Lester D. Thompson, MD

Imaging findings of elastofibromas show poorly circumscribed, heterogenous soft-tissue masses that have contrast enhancement, quite frequently bilateral.