Objective: To assess late histopathologic changes of the soft palate after laser-assisted uvulopa... more Objective: To assess late histopathologic changes of the soft palate after laser-assisted uvulopalatoplasty in pa- tients with snoring and mild obstructive sleep apnea. Design: A nonrandomized, histopathologic controlled study. Subjects and Interventions: Palatal surgical speci- mens were removed from 10 patients with snoring and obstructive sleep apnea in whom laser-assisted uvulo- palatoplasty was not successful and who subsequently underwent uvulopalatopharyngoplasty.
Further study on the composition and concentration of normal nasal mucosal glycoconjugates is nee... more Further study on the composition and concentration of normal nasal mucosal glycoconjugates is needed. A battery of ten lectins was used to stain six carbohydrates residing in the inferior turbinate mucosa of 21 healthy individuals. The concentrations of glycoconjugates of the glycocalyx exceeded that of epithelial goblet, ciliated, and basal cells, and also of mucous, serous, and mixed submucosal glands. Epithelial goblet cells and submucosal mucous glands contained relatively high concentrations of glycoconjugates, whereas in epithelial ciliated and basal cells, similar to serous and mixed submucosal glands, concentrations were scanty. The concentrations of N-acetylgalactosamine and galactose were higher in goblet cells than in mucous glands (p = 0.006, and p = 0.056, respectively). Differences in the concentrations of N-acetylglucosamine, fucose, mannose, and sialic acid were insignificant. The findings provide a baseline for comparison of the composition and concentration of carb...
To study morphometric and qualitative histopathologic changes of the soft palate and uvula in pat... more To study morphometric and qualitative histopathologic changes of the soft palate and uvula in patients with mild, moderate, and severe obstructive sleep apnea. A prospective, nonrandomized controlled study. The distal soft palate and uvula were excised during uvulopalatopharyngoplasty from 34 male patients with obstructive sleep apnea. Control specimens were retrieved from 7 male cadavers with no related disorders. All specimens underwent routine processing and the mid-sagittal sections were studied. Morphometric analysis of the relative proportions of the tissue constituents was carried out. Also, a qualitative assessment was performed to detect possible pathologic changes. The body mass index of patients was significantly higher from that of control subjects. The area fraction occupied by the tissue constituents of the distal portion of the soft palate and uvula in patients with mild, moderate, and severe obstructive sleep apnea and in control subjects was similar, with small and ...
To study the arterial architecture of the normal inferior turbinate. A prospective, nonrandomized... more To study the arterial architecture of the normal inferior turbinate. A prospective, nonrandomized, histologic study. Fourteen samples were removed at autopsy and during septoplasty operations, processed in the usual manner, stained with hematoxylin-eosin, and investigated microscopically. The analysis included data on the number, location within or outside the bone, the mean area, wall thickness, and distance the arteries traverse from the point of entrance into the bone to the point of exit into the soft tissue. One to three arteries enter the inferior turbinate posteriorly. In 7 of 14 inferior turbinates (50%), the arteries lie within the bone and in 2 (14%) within the soft tissue, and in 5 (36%), a mixed pattern was observed. The arteries run along a mean of 1.2 +/- 0.49 cm before piercing the bone into the soft tissue and split off to one to six branches. The mean area and the mean wall thickness of the arteries at the entrance into the bone posteriorly were significantly greater than that of the arteries emerging from the bone and entering the soft tissue anteriorly (0.099 +/- 0.056 mm2 vs 0.051 +/- 0.022 mm2 [p < .01] and 0.116 +/- 0.042 mm vs 0.083 +/- 0.031 mm [p < .05], respectively). The inferior mucosal layer lacks major arteries. Given the data presented here, the excision of the inferior mucosal layer and the anterior portion of the inferior turbinate bone distal to the point of arterial exit constitute a relatively low risk for postoperative arterial bleeding.
To evaluate the long-term results of fat graft myringoplasty in adult and pediatric populations. ... more To evaluate the long-term results of fat graft myringoplasty in adult and pediatric populations. Prospective case series study. Patients with chronic tympanic membrane perforations were considered candidates for fat graft myringoplasty. Excluded were patients with purulent discharge, suspected ossicular disease, suspected cholesteatoma, or a perforation diameter greater than 6.5 mm. Fat was harvested from the ear lobule or subcutaneous tissue just posterior-inferior to the lobule. The study population comprised 27 adults and 11 children. Twenty-eight perforations were small (73.7%) and 10 were large (26.3%). Altogether, 31 of 38 perforations were successfully repaired (81.6%), including 22 of 28 small perforations (78.6%) and 9 of 10 large perforations (90%). Assessment by age showed that 23 of 27 perforations of the adults (85.2%) and 8 of 11 perforations of the children (72.7%) successfully closed (p = .648). Follow-up ranged from 25 to 53 months (mean 40.6 +/- 8.3 months). No recurrence of the perforation during the follow-up period was recorded if the initial results were successful. The speech reception threshold improved significantly (18.5 +/- 7.7 dB vs 23.5 +/- 8 dB; p = .043). No significant sensorineural hearing loss occurred. Fat graft myringoplasty is a reliable technique for the closure of small- and medium-sized perforations. The grafting results showed excellent long-term durability. Given the simplicity of the technique, its short duration, and the favourable hearing results, fat graft myringoplasty should be considered the procedure of choice in patients with suitable perforations and when not otherwise contraindicated.
The histopathologic findings in 8 temporal bones from 5 patients with osteogenesis imperfecta con... more The histopathologic findings in 8 temporal bones from 5 patients with osteogenesis imperfecta congenita are reported. The otic capsule, bony walls of middle ear, and ossicles showed evidence of both deficient and abnormal ossification. Microfractures were found in the otic capsule and in the anterior process and handle of the malleus, in addition to their common location at the crura of the stapes. The cochlear and vestibular end-organs appeared normal. Pathologic changes compatible with otosclerosis were not seen. The possible implication of these changes on hearing and balance is discussed.
The traditional lateral-view cephalometric analysis is limited because it provides only two-dimen... more The traditional lateral-view cephalometric analysis is limited because it provides only two-dimensional analysis of the three-dimensional craniofacial structure. The objectives were to analyze lateral and frontal cephalometric radiographs in a series of normal patients and those with varying degrees of sleep-disordered breathing and to define the degrees of narrowing or other unfavorable anatomical changes that might differentiate the patients with sleep-disordered breathing from normal subjects. A prospective study of 100 adult patients with sleep-disordered breathing and 60 age-matched normal subjects. An analysis of the lateral and frontal cephalometric measurements was performed to assess velopharyngeal anatomical features. A comparison was made between the patients' polysomnographic and cephalometric analyses. The compromised cephalometric parameters that may be found in patients with sleep-disordered breathing include acute skull-base and bony nasopharynx angles, inferior hyoid position, thickening of the velum, reduced retrovelar posterior air space along with thickening of the velum, thickening of the posterior pharyngeal wall, and narrowing of the velopharyngeal lumen. Worsening of sleep-disordered breathing was generally associated with increased numbers of compromised cephalometric parameters. As body mass index increases, there is reduced velopharyngeal width, the velum thickness is increased, and the posterior pharyngeal wall thickness is increased. Sleep-disordered breathing is associated with statistically significant changes in a number of cephalometric measurements. Frontal cephalometric analysis adds further information regarding the anatomical assessment of patients with upper airway obstruction, enhancing the traditional lateral cephalometric view.
To provide data on the histopathological and immunohistochemical characteristics of acute sinusit... more To provide data on the histopathological and immunohistochemical characteristics of acute sinusitis in humans. A nonrandomized, retrospective, controlled, qualitative and quantitative study. Inflamed sinus mucosal tissues were removed during functional endoscopic sinus surgery from 11 patients with acute sinusitis, of whom 6 had complications with extension of inflammation to the orbit (4) or the meninges (2), 3 had recurrent sinusitis, and 2 had acute exacerbation of chronic sinusitis Normal sinus mucosal tissues were retrieved from four patients with various nasal tumors and served as controls All specimens underwent routine histological processing. Representative sections from each region were stained with hematoxylin and eosin, periodic acid-Schiff, and toluidine blue. Immunohistochemical staining for T and B lymphocytes was also applied. A two-phase examination was designed: low-magnification microscopic assessment (x40) to yield the typical pathological features and high-magnification assessment (x400) to count various inflammatory cells. The lamina propria displayed the most significant changes with edema, extensive infiltration of neutrophils and mononuclear cells, formation of microabscesses, thrombophlebitis, and necrotic foci, whereas the involvement of the epithelial layer in the inflammatory reaction was relatively modest. Immunohistochemistry revealed an increase in the population of T and B lymphocytes. The former were diffusely scattered, whereas the latter also formed distinct clusters: around small venules, adjacent to seromucous glands, and under the epithelium. The inflammatory reaction of the lamina propria exceeded that of the epithelial layer. It is assumed that the clusters of B lymphocytes around blood vessels may point to the fact that these cells were recruited from the blood during acute sinusitis.
To study the histological and morphometric features of the normal inferior turbinate. A prospecti... more To study the histological and morphometric features of the normal inferior turbinate. A prospective, nonrandomized study. Sixteen specimens were removed at autopsy and during septoplasty operations, stained with H&E, and investigated microscopically. The soft tissue and bony elements were measured. Morphometric analysis included measurements of the relative proportions of the soft tissue constituents. The medial mucosal layer is thicker than the bone and the lateral mucosa; the difference between the mucosal layers is statistically significant. The inferior turbinate is almost exclusively covered with a pseudostratified ciliated columnar epithelium that houses more goblet cells on its lateral side. It has a well-defined basement membrane zone that is significantly thicker on the medial side. The main bulk of the inferior turbinate is the lamina propria that is built of loose connective tissue and superficially harbors an inflammatory cell infiltrate. The area fraction of glands in the lateral mucosa significantly exceeds that of the medial and inferior mucosal layers, whereas that of venous sinusoids varies significantly, with the greatest difference inferiorly. Decreased proportion of glands and an increase in venous sinusoids are associated with advanced age. The cancellous central bony layer is made of interwoven trabeculae and houses the major arterial supply of the turbinate. After the major arteries exit the bone, they lie in the deepest portions of the medial and lateral mucosal layers but are missing from the inferior layer. In-depth histomorphometric analysis can assist in developing new function-preserving approaches to turbinate surgery.
To evaluate the histopathological and immunohistochemical characteristics of chronic sinusitis, w... more To evaluate the histopathological and immunohistochemical characteristics of chronic sinusitis, with reference to the extent of sinus involvement. A nonrandomized, retrospective, controlled qualitative and quantitative study. Twenty-nine adults with refractory chronic sinusitis underwent functional endoscopic sinus surgery. The score of computed tomography scans was used to determine the extent of disease. Six patients with normal sinus mucosae served as control subjects. Specimens underwent routine histological processing and hematoxylin-eosin and periodic acid-Schiff staining. Immunohistochemistry for T and B lymphocytes was applied. Low-magnification microscopy was designed to yield typical pathological features, and high magnification to count various inflammatory cells. Patients were divided into two groups according to their dominant pathological features: 16 had polypoid mucosa and eosinophilia, and 13 had glandular hyperplasia. The number of eosinophils, T and B lymphocytes in the lamina propria was significantly higher in patients with polypoid mucosa and eosinophilia, compared with those with glandular hyperplasia and with normal control subjects, whereas the difference between patients with glandular hyperplasia and control subjects was insignificant. Although the overall inflammatory reaction was relatively modest, nasal polyposis was more prevalent in patients with polypoid mucosa and eosinophilia; likewise, computed tomography revealed a significantly more extensive disease in these patients compared with the patients with glandular hyperplasia. Two pathophysiological pathways, inducing prolonged obstruction to the outflow of sinus secretion and ultimately causing chronic inflammation, are suggested: 1) swollen polypoid mucosa with activation of eosinophils that damage the epithelium and 2) continued increased mucus secretion originated from hyperplastic submucosal seromucous glands.
To measure the dimensions, composition, and possible structural and/or histopathological changes ... more To measure the dimensions, composition, and possible structural and/or histopathological changes of the compensatory hypertrophic inferior turbinate in patients with deviated nasal septum. A prospective, nonrandomized, and morphometric study. Nineteen patients with deviated nasal septum and compensatory hypertrophy of the inferior turbinate in the contralateral nasal cavity underwent surgery for correction of nasal obstruction. Patients' specimens were compared with those of a control group consisting of 10 inferior turbinates removed at autopsy. Quantitative measurements of the inferior turbinate histological sections were carried out and included the width of the layers and morphometric calculations of the relative proportions of the soft tissue constituents. Also, qualitative study was performed to detect pathological changes. Of all layers, the inferior turbinate bone underwent a twofold increase in thickness and manifested the most significant expansion (P < or =.001), whereas the contribution of the mucosal layers to the inferior turbinate hypertrophy was modest. The morphometric analysis revealed a larger proportion of venous sinusoids in hypertrophic turbinates, but the difference was small and statistically insignificant. Qualitative assessment disclosed normal mucosal architecture in all inferior turbinates with compensatory hypertrophy. Eleven remained intact, while eight disclosed mild to moderate pathological changes. The data gathered in the present study are of importance to the decision-making process regarding turbinate surgery. The significant bone expansion and the relative minor role played by the mucosal hypertrophy would support the decision to excise the inferior turbinate bone at the time of septoplasty.
The inhibitory effects of ketotifen, a histamine H1-receptor antagonist and mast cell stabilizer,... more The inhibitory effects of ketotifen, a histamine H1-receptor antagonist and mast cell stabilizer, were examined on a non-IgE experimental model of middle ear effusion. Thirty rats were divided into three groups. Group A (n = 9) was subjected to mechanical stimulation of the external auditory canal (EAC); group B (n = 11) was pre-treated with intraperitoneal administration of 0.2 mg ketotifen, 90 min before mechanical stimulation of the EAC; and group C (n = 10), the control group, was neither exposed to mechanical stimulation nor given ketotifen. Thirty minutes after completion of the experiment, the eardrums were inspected, histamine levels were determined by a fluorometric assay, and the pars flaccida underwent histological assessment. An attic effusion was observed in group A; a similar phenomenon but to a lesser extent was also seen in group B. Statistical analysis confirmed that the mean histamine concentration of the rinsing fluid obtained from group A was significantly higher than that of group C (p = 0.004) or group B (p = 0.008). No significant difference was found between the mean histamine concentration of groups C and group B (p = 0.311). Histological assessment revealed that the thickness of the pars flaccida of group A was considerably greater than that of groups C and B and was characterized by marked edema. Furthermore, the pars flaccida mast cell population was significantly depleted compared with groups C and B. The data indicate that mechanical stimulation of the EAC triggered the pars flaccida mast cells to degranulate in a non-mediated IgE fashion and that histamine is implicated in most of these histological changes. It is concluded that administration of ketotifen before mechanical stimulation of the EAC had a stabilizing effect and abolished mast cell degranulation, therefore, may be considered as a potential therapeutic agent for the treatment of middle ear disease in the pediatric population.
To study the histology of the normal and pathologic middle turbinate (MT). Nonrandomized, control... more To study the histology of the normal and pathologic middle turbinate (MT). Nonrandomized, controlled study. Qualitative and quantitative assessment of soft tissue and bony elements of 14 normal and 10 chronic rhinosinusitis (CRS) MT samples (patients' mean CT score, 6.5 +/- 6.7). A comparison with 14 normal inferior turbinate (IT) samples was accomplished. Quantitative assessment was limited to the lateral mucosal layer (LML). The thickness of the LML was significantly greater in pathologic MT than in normal MT (P = 0.002). Except for veins that underwent significant increase (P = 0.036), other soft tissue constituents of the pathologic MT did not change significantly. Glands were more abundant in normal MT and veins in normal IT (P < 0.001, P = 0.001, respectively). Qualitative assessment showed larger veins in the normal IT compared with the normal MT. Inflammatory cell infiltrate, edema, and fibrosis were found in CRS. None of our MT bones exhibited osteomyelitic changes. The different proportion of glands suggests varied functional roles for both the MT and IT. The significant involvement of the MT in the inflammatory process of CRS and the relatively small size and paucity of veins with relatively little effect on nasal airflow justify partial excision of the MT.
To assess the characteristics of adult vallecular cyst. A retrospective chart review from a unive... more To assess the characteristics of adult vallecular cyst. A retrospective chart review from a university affiliated hospital. Clinical manifestations and airway management of 38 consecutive adult patients with vallecular cyst admitted between 1992 and 2004 were studied. Two distinct groups were identified: infected (n = 24) and noninfected (n = 14). Twenty-two (91.7%) patients of the former group had acute epiglottitis with an abrupt onset culminating in abscess formation in 19 (79.2%) and airway compromise in 9 (37.5%) compared with none in the noninfected group (P = 0.006). In 4 (18.2%) of 22 patients, the origin of the infected vallecular cyst was evident only after symptoms subsided. Three patients had recurrent acute epiglottitis. The noninfected group had a relatively prolonged mild clinical course. Two types of vallecular cysts were characterized. Abscess formation was the hallmark of adult infected vallecular cyst. To improve patient care, endoscopic follow-up is advocated. In patients with recurrent episodes of acute epiglottitis, imaging is recommended.
In this study we sought to define the histologic changes produced by laser treatment of inferior ... more In this study we sought to define the histologic changes produced by laser treatment of inferior turbinates. Eight inferior turbinates with prior laser treatment (mean, 26.8 months) were analyzed by light microscopy after turbinectomy for relief of refractory nasal obstruction. Histologic findings were compared with those of a group of 8 hypertrophic inferior turbinates that had no previous laser surgery. Laser-treated areas of the inferior turbinates demonstrated a histologically bland appearance, with marked diminution of seromucinous glands and relative preponderance of connective tissue matrix. Prominence of venous sinusoids was also significantly reduced in the laser-treated areas. Surface epithelium including goblet cells was reconstituted over the areas of laser application. Clinical laser surgery of the inferior turbinate produces striking long-term histologic changes. The data suggest a differential response of turbinate histologic components to application of laser energy, with the glandular component being particularly sensitive. Further correlative study is needed to clarify the clinical significance of laser-induced histologic changes in inferior turbinates.
Obesity can cause disturbed breathing and is one of the most significant risk factors for obstruc... more Obesity can cause disturbed breathing and is one of the most significant risk factors for obstructive sleep apnea (OSA). However, the anatomic basis of OSA and, specifically, the anatomic mechanisms leading from obesity to OSA are still unclear. We examined the anatomic features of the velopharynx in patients with OSA versus those without in correlation with the body mass index (BMI), age, history of snoring, and OSA severity and re-evaluated the contribution of adding a frontal view to the cephalometric analysis of patients with OSA. Lateral and frontal cephalometric measurements were taken to assess the velopharyngeal anatomic features of 306 men with various degrees of OSA and 64 men without OSA and without a history of snoring. The demographic, polysomnographic, and cephalometric features were compared. The patients with OSA had an increased pharyngeal length, thicker velum, a thicker posterior pharyngeal wall, a reduced pharyngeal width, and a consequent narrowing of the pharyngeal lumen. As the BMI increased, the OSA severity increased. Also, in parallel, the velum and posterior pharyngeal wall thickness increased and the pharyngeal width decreased. Three types of velopharyngeal narrowing, with an increased occurrence in severe degrees of OSA, were identified: bottle shape, hourglass shape, and tube shape. These aerodynamically unfavorable changes might cause increased upper airway resistance, explaining the development of both OSA and hypoventilation syndrome in obese patients. Velopharyngeal thickening and lumen narrowing were shown to be features of obese men with OSA. However, these features developed only above a threshold BMI value. The combination of frontal and lateral cephalometry is important for comprehensive evaluation of patients with OSA.
The aim of the study was to estimate the sensitivity and specificity of endoscopy and the diagnos... more The aim of the study was to estimate the sensitivity and specificity of endoscopy and the diagnostic value of clinical criteria for acute bacterial rhinosinusitis (ABRS). The hospital records of 117 consecutive patients who had symptoms compatible with ABRS and who underwent sinus radiography and flexible nasendoscopy were retrieved. A positive diagnosis was entertained when radiography demonstrated air fluid level, complete opacification or at least 6 mm mucosal thickening and/or endoscopy revealed purulent material within the drainage area of the sinuses. Using a modified version of the Hui and Walter procedure, the sensitivity and specificity of nasendoscopy was calculated against sinus radiography, a standard reference test, with known estimated sensitivity (76%) and specificity (79%). The findings show that 40 patients (34%) had positive endoscopy and radiography. Twenty patients (17%) had positive endoscopy and negative radiography, and vice versa in 15 (13%). In 42 patients (36%) both modalities were negative. Endoscopy yielded a sensitivity of 80% (95% CI, 0.55-1.00) and a specificity of 94% (95% CI, 0.33-1.00). Although estimates seem better than those of radiography, the confidence intervals are quite wide and no firm conclusion is drawn. Neither single nor combination of symptoms, concurrent with two major and one minor factor advocated by the AAO-HNS Task Force on Rhinosinusitis, were associated with a positive diagnosis of ABRS. The data suggest that endoscopy is no less effective than radiography in predicting ABRS, also that clinical criteria are of rather limited diagnostic value, and thus should be supported by other diagnostic tests. Endoscopy is recommended as a first line diagnostic tool for the diagnosis of ABRS in routine ENT practice. If the outcome is negative, radiography may follow.
"Hot potato voice" is a characteristic sign of peritonsillar abscess and perito... more "Hot potato voice" is a characteristic sign of peritonsillar abscess and peritonsillitis. Our findings show that the hot potato voice is the result of an underlying transient velopharyngeal insufficiency combined with muffled oral resonance. The hot potato voice should be distinguished from the muffled oral voice which can be occasionally encountered in cases of severe tonsillitis. The velopharyngeal insufficiency is the result of transient dysfunction of the palatal muscles on the affected side. Transient negative middle-ear pressure indicating eustachian tube dysfunction was found in few of the patients in whom concomitant sinusitis was also present. The clinical, nasendoscopic, and radiologic findings are analyzed and discussed. We believe that this phenomenon is valuable as a research tool for the investigation of the anatomy and physiology of the velopharyngeal valve.
Archives of Otolaryngology–Head & Neck Surgery, 2006
To analyze the quantitative and qualitative characteristics of the hypertrophic inferior turbinat... more To analyze the quantitative and qualitative characteristics of the hypertrophic inferior turbinate (IT). A prospective, nonrandomized, controlled, morphometric study. University-affiliated hospital. Subjects Seventeen patients with refractory IT hypertrophy and 12 with normal ITs. Twenty ITs were removed from patients with refractory IT hypertrophy and 14 from patients with normal ITs. The soft tissue and bony elements and the relative proportions of the soft tissue constituents of the hypertrophic and normal ITs were measured and compared. The Bonferroni correction was used to adjust for multiple comparisons. Qualitative assessment was performed to assess possible pathologic changes in all IT tissues. The hypertrophic ITs were significantly wider. The medial mucosal layer, which thickened from a mean +/- SD of 1.39 +/- 0.28 mm to 2.53 +/- 0.56 mm (P</=.001), made the greatest contribution to the total increase in the width of the IT (64.4%). The enlargement in width of the lateral mucosal layer from 0.91 +/- 0.26 mm to 1.26 +/- 031 mm was of borderline statistical significance. The portion of the medial, lateral, and inferior layers of the lamina propria that houses inflammatory cells enlarged significantly in patients with IT hypertrophy compared with healthy control subjects. The relative proportion of the connective tissue, submucosal glands, and arteries remained unchanged, whereas that of venous sinusoids increased significantly in all aspects of the hypertrophic mucosa. Fibrosis, inflammation, and engorged venous sinusoids were noted in hypertrophic ITs, yet there was no evidence of tissue destruction. Understanding the histopathology of the hypertrophic IT is imperative for the development and management of IT reduction surgery.
Objective: To assess late histopathologic changes of the soft palate after laser-assisted uvulopa... more Objective: To assess late histopathologic changes of the soft palate after laser-assisted uvulopalatoplasty in pa- tients with snoring and mild obstructive sleep apnea. Design: A nonrandomized, histopathologic controlled study. Subjects and Interventions: Palatal surgical speci- mens were removed from 10 patients with snoring and obstructive sleep apnea in whom laser-assisted uvulo- palatoplasty was not successful and who subsequently underwent uvulopalatopharyngoplasty.
Further study on the composition and concentration of normal nasal mucosal glycoconjugates is nee... more Further study on the composition and concentration of normal nasal mucosal glycoconjugates is needed. A battery of ten lectins was used to stain six carbohydrates residing in the inferior turbinate mucosa of 21 healthy individuals. The concentrations of glycoconjugates of the glycocalyx exceeded that of epithelial goblet, ciliated, and basal cells, and also of mucous, serous, and mixed submucosal glands. Epithelial goblet cells and submucosal mucous glands contained relatively high concentrations of glycoconjugates, whereas in epithelial ciliated and basal cells, similar to serous and mixed submucosal glands, concentrations were scanty. The concentrations of N-acetylgalactosamine and galactose were higher in goblet cells than in mucous glands (p = 0.006, and p = 0.056, respectively). Differences in the concentrations of N-acetylglucosamine, fucose, mannose, and sialic acid were insignificant. The findings provide a baseline for comparison of the composition and concentration of carb...
To study morphometric and qualitative histopathologic changes of the soft palate and uvula in pat... more To study morphometric and qualitative histopathologic changes of the soft palate and uvula in patients with mild, moderate, and severe obstructive sleep apnea. A prospective, nonrandomized controlled study. The distal soft palate and uvula were excised during uvulopalatopharyngoplasty from 34 male patients with obstructive sleep apnea. Control specimens were retrieved from 7 male cadavers with no related disorders. All specimens underwent routine processing and the mid-sagittal sections were studied. Morphometric analysis of the relative proportions of the tissue constituents was carried out. Also, a qualitative assessment was performed to detect possible pathologic changes. The body mass index of patients was significantly higher from that of control subjects. The area fraction occupied by the tissue constituents of the distal portion of the soft palate and uvula in patients with mild, moderate, and severe obstructive sleep apnea and in control subjects was similar, with small and ...
To study the arterial architecture of the normal inferior turbinate. A prospective, nonrandomized... more To study the arterial architecture of the normal inferior turbinate. A prospective, nonrandomized, histologic study. Fourteen samples were removed at autopsy and during septoplasty operations, processed in the usual manner, stained with hematoxylin-eosin, and investigated microscopically. The analysis included data on the number, location within or outside the bone, the mean area, wall thickness, and distance the arteries traverse from the point of entrance into the bone to the point of exit into the soft tissue. One to three arteries enter the inferior turbinate posteriorly. In 7 of 14 inferior turbinates (50%), the arteries lie within the bone and in 2 (14%) within the soft tissue, and in 5 (36%), a mixed pattern was observed. The arteries run along a mean of 1.2 +/- 0.49 cm before piercing the bone into the soft tissue and split off to one to six branches. The mean area and the mean wall thickness of the arteries at the entrance into the bone posteriorly were significantly greater than that of the arteries emerging from the bone and entering the soft tissue anteriorly (0.099 +/- 0.056 mm2 vs 0.051 +/- 0.022 mm2 [p < .01] and 0.116 +/- 0.042 mm vs 0.083 +/- 0.031 mm [p < .05], respectively). The inferior mucosal layer lacks major arteries. Given the data presented here, the excision of the inferior mucosal layer and the anterior portion of the inferior turbinate bone distal to the point of arterial exit constitute a relatively low risk for postoperative arterial bleeding.
To evaluate the long-term results of fat graft myringoplasty in adult and pediatric populations. ... more To evaluate the long-term results of fat graft myringoplasty in adult and pediatric populations. Prospective case series study. Patients with chronic tympanic membrane perforations were considered candidates for fat graft myringoplasty. Excluded were patients with purulent discharge, suspected ossicular disease, suspected cholesteatoma, or a perforation diameter greater than 6.5 mm. Fat was harvested from the ear lobule or subcutaneous tissue just posterior-inferior to the lobule. The study population comprised 27 adults and 11 children. Twenty-eight perforations were small (73.7%) and 10 were large (26.3%). Altogether, 31 of 38 perforations were successfully repaired (81.6%), including 22 of 28 small perforations (78.6%) and 9 of 10 large perforations (90%). Assessment by age showed that 23 of 27 perforations of the adults (85.2%) and 8 of 11 perforations of the children (72.7%) successfully closed (p = .648). Follow-up ranged from 25 to 53 months (mean 40.6 +/- 8.3 months). No recurrence of the perforation during the follow-up period was recorded if the initial results were successful. The speech reception threshold improved significantly (18.5 +/- 7.7 dB vs 23.5 +/- 8 dB; p = .043). No significant sensorineural hearing loss occurred. Fat graft myringoplasty is a reliable technique for the closure of small- and medium-sized perforations. The grafting results showed excellent long-term durability. Given the simplicity of the technique, its short duration, and the favourable hearing results, fat graft myringoplasty should be considered the procedure of choice in patients with suitable perforations and when not otherwise contraindicated.
The histopathologic findings in 8 temporal bones from 5 patients with osteogenesis imperfecta con... more The histopathologic findings in 8 temporal bones from 5 patients with osteogenesis imperfecta congenita are reported. The otic capsule, bony walls of middle ear, and ossicles showed evidence of both deficient and abnormal ossification. Microfractures were found in the otic capsule and in the anterior process and handle of the malleus, in addition to their common location at the crura of the stapes. The cochlear and vestibular end-organs appeared normal. Pathologic changes compatible with otosclerosis were not seen. The possible implication of these changes on hearing and balance is discussed.
The traditional lateral-view cephalometric analysis is limited because it provides only two-dimen... more The traditional lateral-view cephalometric analysis is limited because it provides only two-dimensional analysis of the three-dimensional craniofacial structure. The objectives were to analyze lateral and frontal cephalometric radiographs in a series of normal patients and those with varying degrees of sleep-disordered breathing and to define the degrees of narrowing or other unfavorable anatomical changes that might differentiate the patients with sleep-disordered breathing from normal subjects. A prospective study of 100 adult patients with sleep-disordered breathing and 60 age-matched normal subjects. An analysis of the lateral and frontal cephalometric measurements was performed to assess velopharyngeal anatomical features. A comparison was made between the patients' polysomnographic and cephalometric analyses. The compromised cephalometric parameters that may be found in patients with sleep-disordered breathing include acute skull-base and bony nasopharynx angles, inferior hyoid position, thickening of the velum, reduced retrovelar posterior air space along with thickening of the velum, thickening of the posterior pharyngeal wall, and narrowing of the velopharyngeal lumen. Worsening of sleep-disordered breathing was generally associated with increased numbers of compromised cephalometric parameters. As body mass index increases, there is reduced velopharyngeal width, the velum thickness is increased, and the posterior pharyngeal wall thickness is increased. Sleep-disordered breathing is associated with statistically significant changes in a number of cephalometric measurements. Frontal cephalometric analysis adds further information regarding the anatomical assessment of patients with upper airway obstruction, enhancing the traditional lateral cephalometric view.
To provide data on the histopathological and immunohistochemical characteristics of acute sinusit... more To provide data on the histopathological and immunohistochemical characteristics of acute sinusitis in humans. A nonrandomized, retrospective, controlled, qualitative and quantitative study. Inflamed sinus mucosal tissues were removed during functional endoscopic sinus surgery from 11 patients with acute sinusitis, of whom 6 had complications with extension of inflammation to the orbit (4) or the meninges (2), 3 had recurrent sinusitis, and 2 had acute exacerbation of chronic sinusitis Normal sinus mucosal tissues were retrieved from four patients with various nasal tumors and served as controls All specimens underwent routine histological processing. Representative sections from each region were stained with hematoxylin and eosin, periodic acid-Schiff, and toluidine blue. Immunohistochemical staining for T and B lymphocytes was also applied. A two-phase examination was designed: low-magnification microscopic assessment (x40) to yield the typical pathological features and high-magnification assessment (x400) to count various inflammatory cells. The lamina propria displayed the most significant changes with edema, extensive infiltration of neutrophils and mononuclear cells, formation of microabscesses, thrombophlebitis, and necrotic foci, whereas the involvement of the epithelial layer in the inflammatory reaction was relatively modest. Immunohistochemistry revealed an increase in the population of T and B lymphocytes. The former were diffusely scattered, whereas the latter also formed distinct clusters: around small venules, adjacent to seromucous glands, and under the epithelium. The inflammatory reaction of the lamina propria exceeded that of the epithelial layer. It is assumed that the clusters of B lymphocytes around blood vessels may point to the fact that these cells were recruited from the blood during acute sinusitis.
To study the histological and morphometric features of the normal inferior turbinate. A prospecti... more To study the histological and morphometric features of the normal inferior turbinate. A prospective, nonrandomized study. Sixteen specimens were removed at autopsy and during septoplasty operations, stained with H&E, and investigated microscopically. The soft tissue and bony elements were measured. Morphometric analysis included measurements of the relative proportions of the soft tissue constituents. The medial mucosal layer is thicker than the bone and the lateral mucosa; the difference between the mucosal layers is statistically significant. The inferior turbinate is almost exclusively covered with a pseudostratified ciliated columnar epithelium that houses more goblet cells on its lateral side. It has a well-defined basement membrane zone that is significantly thicker on the medial side. The main bulk of the inferior turbinate is the lamina propria that is built of loose connective tissue and superficially harbors an inflammatory cell infiltrate. The area fraction of glands in the lateral mucosa significantly exceeds that of the medial and inferior mucosal layers, whereas that of venous sinusoids varies significantly, with the greatest difference inferiorly. Decreased proportion of glands and an increase in venous sinusoids are associated with advanced age. The cancellous central bony layer is made of interwoven trabeculae and houses the major arterial supply of the turbinate. After the major arteries exit the bone, they lie in the deepest portions of the medial and lateral mucosal layers but are missing from the inferior layer. In-depth histomorphometric analysis can assist in developing new function-preserving approaches to turbinate surgery.
To evaluate the histopathological and immunohistochemical characteristics of chronic sinusitis, w... more To evaluate the histopathological and immunohistochemical characteristics of chronic sinusitis, with reference to the extent of sinus involvement. A nonrandomized, retrospective, controlled qualitative and quantitative study. Twenty-nine adults with refractory chronic sinusitis underwent functional endoscopic sinus surgery. The score of computed tomography scans was used to determine the extent of disease. Six patients with normal sinus mucosae served as control subjects. Specimens underwent routine histological processing and hematoxylin-eosin and periodic acid-Schiff staining. Immunohistochemistry for T and B lymphocytes was applied. Low-magnification microscopy was designed to yield typical pathological features, and high magnification to count various inflammatory cells. Patients were divided into two groups according to their dominant pathological features: 16 had polypoid mucosa and eosinophilia, and 13 had glandular hyperplasia. The number of eosinophils, T and B lymphocytes in the lamina propria was significantly higher in patients with polypoid mucosa and eosinophilia, compared with those with glandular hyperplasia and with normal control subjects, whereas the difference between patients with glandular hyperplasia and control subjects was insignificant. Although the overall inflammatory reaction was relatively modest, nasal polyposis was more prevalent in patients with polypoid mucosa and eosinophilia; likewise, computed tomography revealed a significantly more extensive disease in these patients compared with the patients with glandular hyperplasia. Two pathophysiological pathways, inducing prolonged obstruction to the outflow of sinus secretion and ultimately causing chronic inflammation, are suggested: 1) swollen polypoid mucosa with activation of eosinophils that damage the epithelium and 2) continued increased mucus secretion originated from hyperplastic submucosal seromucous glands.
To measure the dimensions, composition, and possible structural and/or histopathological changes ... more To measure the dimensions, composition, and possible structural and/or histopathological changes of the compensatory hypertrophic inferior turbinate in patients with deviated nasal septum. A prospective, nonrandomized, and morphometric study. Nineteen patients with deviated nasal septum and compensatory hypertrophy of the inferior turbinate in the contralateral nasal cavity underwent surgery for correction of nasal obstruction. Patients' specimens were compared with those of a control group consisting of 10 inferior turbinates removed at autopsy. Quantitative measurements of the inferior turbinate histological sections were carried out and included the width of the layers and morphometric calculations of the relative proportions of the soft tissue constituents. Also, qualitative study was performed to detect pathological changes. Of all layers, the inferior turbinate bone underwent a twofold increase in thickness and manifested the most significant expansion (P < or =.001), whereas the contribution of the mucosal layers to the inferior turbinate hypertrophy was modest. The morphometric analysis revealed a larger proportion of venous sinusoids in hypertrophic turbinates, but the difference was small and statistically insignificant. Qualitative assessment disclosed normal mucosal architecture in all inferior turbinates with compensatory hypertrophy. Eleven remained intact, while eight disclosed mild to moderate pathological changes. The data gathered in the present study are of importance to the decision-making process regarding turbinate surgery. The significant bone expansion and the relative minor role played by the mucosal hypertrophy would support the decision to excise the inferior turbinate bone at the time of septoplasty.
The inhibitory effects of ketotifen, a histamine H1-receptor antagonist and mast cell stabilizer,... more The inhibitory effects of ketotifen, a histamine H1-receptor antagonist and mast cell stabilizer, were examined on a non-IgE experimental model of middle ear effusion. Thirty rats were divided into three groups. Group A (n = 9) was subjected to mechanical stimulation of the external auditory canal (EAC); group B (n = 11) was pre-treated with intraperitoneal administration of 0.2 mg ketotifen, 90 min before mechanical stimulation of the EAC; and group C (n = 10), the control group, was neither exposed to mechanical stimulation nor given ketotifen. Thirty minutes after completion of the experiment, the eardrums were inspected, histamine levels were determined by a fluorometric assay, and the pars flaccida underwent histological assessment. An attic effusion was observed in group A; a similar phenomenon but to a lesser extent was also seen in group B. Statistical analysis confirmed that the mean histamine concentration of the rinsing fluid obtained from group A was significantly higher than that of group C (p = 0.004) or group B (p = 0.008). No significant difference was found between the mean histamine concentration of groups C and group B (p = 0.311). Histological assessment revealed that the thickness of the pars flaccida of group A was considerably greater than that of groups C and B and was characterized by marked edema. Furthermore, the pars flaccida mast cell population was significantly depleted compared with groups C and B. The data indicate that mechanical stimulation of the EAC triggered the pars flaccida mast cells to degranulate in a non-mediated IgE fashion and that histamine is implicated in most of these histological changes. It is concluded that administration of ketotifen before mechanical stimulation of the EAC had a stabilizing effect and abolished mast cell degranulation, therefore, may be considered as a potential therapeutic agent for the treatment of middle ear disease in the pediatric population.
To study the histology of the normal and pathologic middle turbinate (MT). Nonrandomized, control... more To study the histology of the normal and pathologic middle turbinate (MT). Nonrandomized, controlled study. Qualitative and quantitative assessment of soft tissue and bony elements of 14 normal and 10 chronic rhinosinusitis (CRS) MT samples (patients' mean CT score, 6.5 +/- 6.7). A comparison with 14 normal inferior turbinate (IT) samples was accomplished. Quantitative assessment was limited to the lateral mucosal layer (LML). The thickness of the LML was significantly greater in pathologic MT than in normal MT (P = 0.002). Except for veins that underwent significant increase (P = 0.036), other soft tissue constituents of the pathologic MT did not change significantly. Glands were more abundant in normal MT and veins in normal IT (P < 0.001, P = 0.001, respectively). Qualitative assessment showed larger veins in the normal IT compared with the normal MT. Inflammatory cell infiltrate, edema, and fibrosis were found in CRS. None of our MT bones exhibited osteomyelitic changes. The different proportion of glands suggests varied functional roles for both the MT and IT. The significant involvement of the MT in the inflammatory process of CRS and the relatively small size and paucity of veins with relatively little effect on nasal airflow justify partial excision of the MT.
To assess the characteristics of adult vallecular cyst. A retrospective chart review from a unive... more To assess the characteristics of adult vallecular cyst. A retrospective chart review from a university affiliated hospital. Clinical manifestations and airway management of 38 consecutive adult patients with vallecular cyst admitted between 1992 and 2004 were studied. Two distinct groups were identified: infected (n = 24) and noninfected (n = 14). Twenty-two (91.7%) patients of the former group had acute epiglottitis with an abrupt onset culminating in abscess formation in 19 (79.2%) and airway compromise in 9 (37.5%) compared with none in the noninfected group (P = 0.006). In 4 (18.2%) of 22 patients, the origin of the infected vallecular cyst was evident only after symptoms subsided. Three patients had recurrent acute epiglottitis. The noninfected group had a relatively prolonged mild clinical course. Two types of vallecular cysts were characterized. Abscess formation was the hallmark of adult infected vallecular cyst. To improve patient care, endoscopic follow-up is advocated. In patients with recurrent episodes of acute epiglottitis, imaging is recommended.
In this study we sought to define the histologic changes produced by laser treatment of inferior ... more In this study we sought to define the histologic changes produced by laser treatment of inferior turbinates. Eight inferior turbinates with prior laser treatment (mean, 26.8 months) were analyzed by light microscopy after turbinectomy for relief of refractory nasal obstruction. Histologic findings were compared with those of a group of 8 hypertrophic inferior turbinates that had no previous laser surgery. Laser-treated areas of the inferior turbinates demonstrated a histologically bland appearance, with marked diminution of seromucinous glands and relative preponderance of connective tissue matrix. Prominence of venous sinusoids was also significantly reduced in the laser-treated areas. Surface epithelium including goblet cells was reconstituted over the areas of laser application. Clinical laser surgery of the inferior turbinate produces striking long-term histologic changes. The data suggest a differential response of turbinate histologic components to application of laser energy, with the glandular component being particularly sensitive. Further correlative study is needed to clarify the clinical significance of laser-induced histologic changes in inferior turbinates.
Obesity can cause disturbed breathing and is one of the most significant risk factors for obstruc... more Obesity can cause disturbed breathing and is one of the most significant risk factors for obstructive sleep apnea (OSA). However, the anatomic basis of OSA and, specifically, the anatomic mechanisms leading from obesity to OSA are still unclear. We examined the anatomic features of the velopharynx in patients with OSA versus those without in correlation with the body mass index (BMI), age, history of snoring, and OSA severity and re-evaluated the contribution of adding a frontal view to the cephalometric analysis of patients with OSA. Lateral and frontal cephalometric measurements were taken to assess the velopharyngeal anatomic features of 306 men with various degrees of OSA and 64 men without OSA and without a history of snoring. The demographic, polysomnographic, and cephalometric features were compared. The patients with OSA had an increased pharyngeal length, thicker velum, a thicker posterior pharyngeal wall, a reduced pharyngeal width, and a consequent narrowing of the pharyngeal lumen. As the BMI increased, the OSA severity increased. Also, in parallel, the velum and posterior pharyngeal wall thickness increased and the pharyngeal width decreased. Three types of velopharyngeal narrowing, with an increased occurrence in severe degrees of OSA, were identified: bottle shape, hourglass shape, and tube shape. These aerodynamically unfavorable changes might cause increased upper airway resistance, explaining the development of both OSA and hypoventilation syndrome in obese patients. Velopharyngeal thickening and lumen narrowing were shown to be features of obese men with OSA. However, these features developed only above a threshold BMI value. The combination of frontal and lateral cephalometry is important for comprehensive evaluation of patients with OSA.
The aim of the study was to estimate the sensitivity and specificity of endoscopy and the diagnos... more The aim of the study was to estimate the sensitivity and specificity of endoscopy and the diagnostic value of clinical criteria for acute bacterial rhinosinusitis (ABRS). The hospital records of 117 consecutive patients who had symptoms compatible with ABRS and who underwent sinus radiography and flexible nasendoscopy were retrieved. A positive diagnosis was entertained when radiography demonstrated air fluid level, complete opacification or at least 6 mm mucosal thickening and/or endoscopy revealed purulent material within the drainage area of the sinuses. Using a modified version of the Hui and Walter procedure, the sensitivity and specificity of nasendoscopy was calculated against sinus radiography, a standard reference test, with known estimated sensitivity (76%) and specificity (79%). The findings show that 40 patients (34%) had positive endoscopy and radiography. Twenty patients (17%) had positive endoscopy and negative radiography, and vice versa in 15 (13%). In 42 patients (36%) both modalities were negative. Endoscopy yielded a sensitivity of 80% (95% CI, 0.55-1.00) and a specificity of 94% (95% CI, 0.33-1.00). Although estimates seem better than those of radiography, the confidence intervals are quite wide and no firm conclusion is drawn. Neither single nor combination of symptoms, concurrent with two major and one minor factor advocated by the AAO-HNS Task Force on Rhinosinusitis, were associated with a positive diagnosis of ABRS. The data suggest that endoscopy is no less effective than radiography in predicting ABRS, also that clinical criteria are of rather limited diagnostic value, and thus should be supported by other diagnostic tests. Endoscopy is recommended as a first line diagnostic tool for the diagnosis of ABRS in routine ENT practice. If the outcome is negative, radiography may follow.
"Hot potato voice" is a characteristic sign of peritonsillar abscess and perito... more "Hot potato voice" is a characteristic sign of peritonsillar abscess and peritonsillitis. Our findings show that the hot potato voice is the result of an underlying transient velopharyngeal insufficiency combined with muffled oral resonance. The hot potato voice should be distinguished from the muffled oral voice which can be occasionally encountered in cases of severe tonsillitis. The velopharyngeal insufficiency is the result of transient dysfunction of the palatal muscles on the affected side. Transient negative middle-ear pressure indicating eustachian tube dysfunction was found in few of the patients in whom concomitant sinusitis was also present. The clinical, nasendoscopic, and radiologic findings are analyzed and discussed. We believe that this phenomenon is valuable as a research tool for the investigation of the anatomy and physiology of the velopharyngeal valve.
Archives of Otolaryngology–Head & Neck Surgery, 2006
To analyze the quantitative and qualitative characteristics of the hypertrophic inferior turbinat... more To analyze the quantitative and qualitative characteristics of the hypertrophic inferior turbinate (IT). A prospective, nonrandomized, controlled, morphometric study. University-affiliated hospital. Subjects Seventeen patients with refractory IT hypertrophy and 12 with normal ITs. Twenty ITs were removed from patients with refractory IT hypertrophy and 14 from patients with normal ITs. The soft tissue and bony elements and the relative proportions of the soft tissue constituents of the hypertrophic and normal ITs were measured and compared. The Bonferroni correction was used to adjust for multiple comparisons. Qualitative assessment was performed to assess possible pathologic changes in all IT tissues. The hypertrophic ITs were significantly wider. The medial mucosal layer, which thickened from a mean +/- SD of 1.39 +/- 0.28 mm to 2.53 +/- 0.56 mm (P</=.001), made the greatest contribution to the total increase in the width of the IT (64.4%). The enlargement in width of the lateral mucosal layer from 0.91 +/- 0.26 mm to 1.26 +/- 031 mm was of borderline statistical significance. The portion of the medial, lateral, and inferior layers of the lamina propria that houses inflammatory cells enlarged significantly in patients with IT hypertrophy compared with healthy control subjects. The relative proportion of the connective tissue, submucosal glands, and arteries remained unchanged, whereas that of venous sinusoids increased significantly in all aspects of the hypertrophic mucosa. Fibrosis, inflammation, and engorged venous sinusoids were noted in hypertrophic ITs, yet there was no evidence of tissue destruction. Understanding the histopathology of the hypertrophic IT is imperative for the development and management of IT reduction surgery.
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Papers by Gilead Berger