Eur Arch Otorhinolaryngol (2009) 266:1039–1158 DOI 10.1007/s00405-009-0987-7

ABSTRACTS

Abstracts from the 1st Meeting of EAORL-HNS 27th-30th of June, 2009, Mannheim, Germany

The responsibility for each abstract’s content lies with the respective author(s)
Springer-Verlag 2009 FACIAL PLASTICS

A1 A quantative analyis of the tongue in groove technique with emphasis of tiprotation and projection H. Dool1*, R. Middelweerd2 1 VUmc, Amsterdam, The Netherlands; 2Van Linschoten Specialisten, Hilversum, The Netherlands In nasal tip surgery it is frequently inevitable that some important supporting mechanisms are sacrificed or weakened, this can result in underrotation and decrease of projection in the long-term. A technique that reposition the nasal tip cartilage structures instead of making use of reduction and/or resection is the tongue in groove technique. We present the tongue in groove technique and discuss analysis and results of 9 patients who have been treated by means of this technique. This technique can be particularly used in pronounced underrotation of the nasal tip. The results of the described method are superior to other techniques, the aimed degree of rotation is an indicator for the technique to choose. Potential advantages of this technique are the good impact on rotation with maintenance of nasal tip projection, the reliability for the results in the long-term and bringing back a firm support mechanism of the nasal tip.

A2 Acromegaly: a multidisciplinary treatment

Clinical case: 47-year-old male patient with facial acromegaly stigmas that hinders normal mastication. GH levels during the last year within normal values. Inspection shows a long face, maxillary deficit, mandibular excess and macrocheilia. We realize preoperative and postoperative panoramic and lateral cephalometric X-ray. Surgical technique: 11 mm advance Le Fort I and 8.5 mm midline mandible segmental osteotomy, in order to decrease transversal mandible excess and achieve a class I occlusion. Intermaxillofacial fixation with screw and elastic band class I. Correction of prognathism and adequate zygomatic proyection and vertical shortening of the face can be appreciated postoperatively. Discussion: Acromegaly occurs because of an increase in secretion of growth hormone during the adult stage. It is characterized by bone hyperplasia, glucose intolerance, hypertension, arthritis, soft tissue hyperplasia, organomegaly, muscular weakness, sleep apnea and high output cardiac insufficiency. It is the most commonly caused by a GH secreting adenoma. Its treatment may be surgical, pharmacological or by radiotherapy. Conclusions: • •

• •

Treatment of facial stigmas is carried out after a year with normal GH levels: stabilized acromegaly. Control of the airway in patients with sleep apnea should be emphasized avoiding interdental wire fixation. We avoid setback bilateral sagittal split osteotomy. In the correction of great transversal discrepancies a midline segmental mandible osteotomy may be useful. Some authors perform craniofacial surgery corrections of the acromegaly stigmas.

A3 Case report septal chondroma

U. Bolinaga1*, P. Martinez-Seijas, N. Perez, R. Lobato, J. Arruti, J. Martin 1 Hospital Donostia San Sebastian, Spain

N. Fakih* King Fahed Hospital, Jeddah, Saudi Arabia

Introduction: Facial stigmas secondary to acromegaly confers a characteristic facies and correction is performed when the disease has been stabilized.

17-year-old Saudi male presented 2 years back with total nasal obstruction nasal deformity, CT scan confirm septal tumor biopsy confirm septal chondroma, total removal of the tumor by external

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1040 rhinoplastic and endoscopic approach was done, biopsy done after 1 year confirm no recurrence. Video tape of operation are available.

A4 CO2 versus diode laser in the treatment of chronic hypertrophic rhinitis R. Ungureanu*, C. Manea ENT Department ‘Sfanta Maria’ Hospital, Bucharest, Romania Nasal obstruction causing airway resistance is often a result of structural abnormalities, such as hypertrophy of the inferior turbinates. Usually, turbinate reduction procedures have been used after failure of medical management. Different types of LASERs have been used for reduction of hypertrophic inferior turbinates in recent years. The authors describe their experience regarding the reduction of the inferior turbinates bulking and a comparison between LASER techniques is made. The outcomes of the procedures were evaluated in terms of subjective self-evaluation of the nasal permeability made by the patient itself, persisting rhinorrhea and crusting. The histopathologic aspect of the mucosa after the crust removal was used as an important parameter regarding the mucosal preservation and functioning. The results suggest that the patients experienced better outcomes in the treatment of chronic hypertrophic rhinitis with diode LASER procedures due to the retraction of the turbinates, less crusting and nasal secretions after the operation and better preservation of the mucosa.

A5 Endonasal fixation of shield graft E. Yap1* 1 Metropolitan Hospital, Makati City, Philippines Shield graft is one of the most used graft for tip projection and tip counter rotation. It is usually done in open technique with sutures applied at its edges. This paper demonstrate fixation done endonasally as the last graft procedure wherein the central portion of the shield graft is tied to the intermediate crura using pds 5-0 suture. Tip and pearls as well as pitfalls and solutions to intraop failures will be discussed. A short video will be presented.

A6 Endoscopic resection of nasopharyngeal tumor S. Hao* Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan Background: Nasopharynx lies deep in the skull and is difficult for surgical approach. Tumors arising from nasopharynx are rare and are difficult to resect. We reported our experiences of endoscopic nasopharyngectomy for various pathologies. Methods: From July 1993 to June 2008, 71 cases underwent endoscopic nasopharyngectomy, including curative resection in 16 patients and palliative resection in 55 patients. The surgery was completed under a 4.0 mm 00 Hopkin scope with powerful instruments.

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Results: For the curative resection group of 16 patients, including 7 recurrent nasopharyngeal carcinoma (rNPC), 1 papillary adenocarcinoma, 2 nasopharyngeal angiofibroma, 1 mixed tumor, 2 granuloma, 1 hemangioma, 1 branchial cleft cyst and one epithelial cyst, only one patient with juvenile nasopharyngeal angiofibroma and 2 patients with rNPC had residual or recurrent tumor and all the other 13 patients had no evidence of recurrence. For the 55 patients with palliative nasopharyngectomies, two out of the 52 osteoradionecrosis patients died of carotid artery blow out, one recurrent adenocystic carcinoma patient died of disease, and all the other 52 patients remained alive. There was no major complications, except one intraoperative life-threatening massive bleeding from internal carotid artery in a juvenile nasopharyngeal angiofibroma patient. Conclusions: Endoscopic resection of nasopharyngeal tumor is safe and feasible, even in malignancies. However, patient selection is highly recommended to avoid lethal complications.

A7 Esthesioneuroblastoma in maxillary sinus: case report J. Fejza Bulaj* ENT Department, Tirana University Hospital Center’Mother Teresa’, Tirane¨, Albania Introduction: Esthesioneuroblastoma (ENB) is a rare tumor arising from the olfactory epithelium of the nasal vault which frequently invades the cranial base,cranial vault and orbit. ENB has a bimodal age distribution between 11 and 20 years and between 51 and 60 years. ENB accounts for approximately 1 to 5% of intranasal cancers. Objective: To present the case of a rare tumor with unusual site of presentation and to analyze the natural history,treatment and prognosis of this tumor, based on the literature review. Case report: 44-year-old female was presented at our ENT clinic with the only complaint: numbness of the left part of the face which began 3 months ago. In clinical examination she resulted normal.Cranial CT scan and MRI revealed a tumor mass that occupied the left maxillary sinus,the infundibulum and a part of the left ethmoid cells. Lamina cribrosa was not invaded by the tumor. Results: The biopsy of the mass revealed an esthesioneuroblastoma. It was classified Kadish stage B. The treatment consisted in left maxillectomy and ethmoidectomy combined with radiotherapy and chemotherapy. She had no recurrence after 1 year. Conclusions: ENB is a very uncommon malignant tumor arising from the olfactory epithelium characterized by frequent local or regional recurrence. Radical craniofacial surgery combined with radiotherapy and chemotherapy is probably the most adequate treatment.

A8 Esthesioneuroblastoma: 20-year experience J. Nasello*, I. Kaimen, A. Terzia´n Otolaryngology Head and Neck Surgery, Clinic Hospital, University of Buenos Aires, Buenos Aires, Argentina Objectives: To evaluate outcomes for patients with esthesioneuroblastoma treated at a single institution during 20-years period. Design: Sixteen patients with pathologic diagnosis of esthesioneuroblastoma between 1980 and 2001 were retrospectively identified.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Results: At presentation 12.5% had cervical metastases. None had distant metastasis. One patient had Kadish A, six had Kadish B and nine had Kadish C disease. The mean follow-up was 78 months. Treatment regimens consisted of surgery alone (ten patients), surgery followed by postoperative radiation (two patients), preoperative radiotherapy (two patients) and surgery followed by chemoradiotherapy (one patient). Surgical approaches (n = 16) consisted of 15 craniofacial resections and one endoscopic resection. The 10-years disease-specific survival was 75%. The overall recurrence-free survival at 5 and 10 years was 78 and 55%, respectively. Recurrence was seen in 31.25% with local and regional disease recurrence at 12.5 and 18.75%, respectively. Conclusion: Surgery with craniofacial resection is the preferred treatment. It makes no difference whether radiotherapy is given pre or postsurgical resection. Recurrence can occur even 15 years after treatment. Therefore, long-term follow-up is essential.

A9 Extensive skin metastasis from nasopharyngeal carcinoma in two Malaysian patients: a rare finding M. Y. Mohd Razif1, S. Halimuddin1, S. H. A. Primuharsa Putra2 1 Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia; 2Ear, Nose, ThroatHead and Neck Consultant Clinic, Seremban Specialist Hospital, Seremban, Malaysia

1041 Methods and results: We reported two cases with nasal hemangiomas. A woman (aged 42 years) and a man (aged 23 years), both presented with unilateral obstruction and bleeding. They had no history of trauma or previous surgery. In first case the site of origin was cartilaginous septum, while in second was on the middle nasal turbinate. After radiological studies the tumors were completely removed by the endonasal surgery. Microscopic examination of the tumors revealed capillary type of hemangioma in both cases. Conclusions: Nasal hemangiomas often mimics malignancy. Performing a biopsy is important, but caution should be exercised in case of bleeding. The management of nasal hemangiomas is wide resection with margin of normal mucosa and the uderlying perichondrium.

A11 Impact of rhinoplasty on objective measurement and psychophysical appreciation of facial symmetry R. Nouraei1,2*, M. Pulido1, H. Saleh1 1 Charing Cross Hospital, London, UK; 2The Royal National Throat Nose and Ear Hospital, London, UK

A10 Hemangioma of the nasal cavity: a rare entity

Objectives: To determine the impact of rhinoplasty on the objective measurement and subjective appreciation of facial symmetry, to investigate whether perceptual shifts are correlated with objective changes in facial proportions. Design: Bilateral symmetry ratios of medial and lateral canthi, tragus, ala, and oral commissure were measured in, and Gestalt dichotomous impressions of facial symmetry were obtained for 100 patients before and 6 months after rhinoplasty from frontal view photographs. Paired t test was used to compare facial proportions before and after rhinoplasty. Chi-square was used to compare the proportion of faces perceived as symmetrical before and after surgery. Receiver operator characteristic and analysis of variance were used to assess whether perceptual shifts in symmetry could be correlated with objectively-measurable changes in facial proportion. Results: The proportion of faces perceived as symmetrical increased from 42 to 62 following rhinoplasty (P \ 0.001; chisquare). Objectively, midline-to-ala symmetry increased from an average of 91.1 ± 5.5% to 93.8 ± 4.5% following rhinoplasty (P \ 0.001; paired t test). Other facial proportions did not significantly change. The degree of change in midline-to-ala symmetry was the only objective measure which was significantly associated with the subjective perception of the face as symmetrical or asymmetrical (P \ 0.01; ANOVA). Most positive perceptual shifts were associated with an objective improvement in nasal symmetry that was greater than 2%. Conversely, most negative perceptual shifts were associated with minimal postoperative improvement, or loss of nasal symmetry. Conclusions: Rhinoplasty leads to objectively measurable changes in nasal symmetry which correspond with psychophysical modifications in the perception of a face as symmetrical or asymmetrical.

D. Radaljac1*, Z. Petrovic2, V. Nesic2, T. Radaljac1 1 Hospital Dr M.Marin, Loznica, Serbia; 2Institute of Otorhinolaryngology and Maxillofacial Surgery, CCS, Belgrade, Serbia

A12 Invasive and extensive malignant tumors of the nasal pyramid: clinical cases and surgical techniques

Objective: Hemangiomas are benign vascular tumors that are classified according to their histological appearance into capillary, cavernous, mixed and hypertrophic types. They are the most benign tumors in infancy, but rarely seen in adults. Over half of all hemangiomas are located in the head and neck region, but those of the nasal cavity are rare.

V. Zainea*, R. Hainarosie, I. Postolache, I. Hainarosie, M. Radulescu, A. Ioan, A. Iliescu, V. Cojocaru, D. Dragomir, I. Stoian IFACF-ORL, Bucharest, Romania

Introduction: Nasopharyngeal carcinoma (NPC) constitutes 85% of all malignant tumors of the nasopharynx. It is rare in most parts of the world but occurs with highest incidence among the Southern Chinese population. Though metastatic lung, bone or liver disease is not uncommon on relapse, skin metastasis is rarely reported. We are presenting 2 rare cases of extensive skin metastasis from NPC. Case report/result: We report 2 cases of nasopharyngeal carcinoma with skin metastases. First case (T3, N3a Mo, Stage IVB) develop multiple skin nodules 1 month after completed radical radiotherapy and second case (T3, N3a, M0, stage IVB) develop multiple skin nodules during radiotherapy and concurrent chemotherapy. Biopsy of the skin nodules done confirmed a diagnosis of metastatic nasopharyngeal carcinoma. Both patients were given palliative radiotherapy/ chemotherapy but succumbed to the disease. Conclusion: Patients with skin metastases from NPC is rare and have a very poor prognosis. Early recognition and more effective treatment is essential to improve the outcome of the patients.

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1042 The aim of the paper is to present clinical cases and surgical techniques applied at invasive and malignant tumors of the nasal pyramid. The method consist in presenting 4 selected cases. The reconstructive surgical techniques are illustrated by means of different types of flaps tailed for facial surgery. The tissue expander technology and surgical technique is analysed and mid time results are compare with ‘‘classic’’ techniques of flaps. The results comments the etiology of the tumors, surgical technology applied, and a mid term results. The conclusion is that every case needs its own surgical management and this depend on the experience of the surgeon and the team.

A13 Malignant melanoma of the paranasal sinuses P. Pavlidis*, E. Gletsou, C. Makrypides, E. Theos, C. Evaggelopoulos, C. Gantas, V. Lachanas, T. Apostolidis Otorhinolaryngology, Head and Neck Surgery Department, School of Medicine, University of Thessaly, Larissa, Greece Malignant melanoma of the nose and paranasal sinuses is typically presenting at an advanced stage, with a 5-year survival rate ranging between 20 and 30%. It is an uncommon process, often misdiagnosed both clinically and pathologically. We present the case of a 51-year-old man who had a 5-month history of progressively worsening left-sided epistaxis and nasal obstruction. Clinical examination including endoscopy, as well as imaging studies revealed a soft tissue mass in the left maxillary sinus and nasal cavity resembling massive nasal polyposis and chronic fungal sinusitis. Surgical excision of the mass was conducted. The final pathologic diagnosis was malignant melanoma. Adjuvant chemotherapy followed and the patient survived for 4 years after the initial treatment. Mucosal melanomas of the head and neck region are uncommon lesions and they follow an inexorably aggressive course. Experience with these tumors is, necessarily, limited. At present, surgical excision remains the mainstay of treatment. However, anatomical complexities within the region can hamper attempts of complete excision. Radiotherapy has not been traditionally relied on for routine treatment of mucosal melanomas and chemotherapy is principally employed in the treatment of disseminated disease or for palliation.

A14 Management of esthesioneuroblastoma W. Golabek* Department of Otolaryngology, Head and Neck Surgery, Lublin, Poland Esthesioneuroblastoma is a rare malignant tumour which arises from the olfactory epithelium. The tumour occupies the nasal cavity, ethmoid cells, than other sinuses and orbit. It may also invade anterior and middle cranial fossa. Neck node or distant metastasis may be present at the time of diagnosis (10–30%). Nasal blockage and discharge and loss of smell are initial symptoms. CT and MRI well define extent of tumour, particularly orbital and intracranial invasion which is crutial issue for the patient. Biopsy of tumour reveals proper diagnosis. Hyam proposed histological classification: low-grade and high-grade tumours. Various clinical staging systems have been proposed for esthesioneuroblastoma (Kadish, Biller, Dulguerov). Recent classification of Cantu for ethmoid cancer seems well reflect prognosis for

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 this tumour. Commonly accepted treatment is craniofacial surgery combined with chemoradiotherapy. Surgical approach varies with the extent of the tumour. Skull base resection is accompanied by partial or total maxillectomy or orbitectomy. Initially regular bifrontal craniotomy was performed to get access to an intracranial portion of tumour and skull base. Than small window frontal craniotomy (Cheesman, Raveh) and subcranial approach have been used to the skull base. Recently endoscopic resection is performed for anterior skull base tumours by experienced surgeons. 5-year survival is reported in 38– 82% of patients, though recurrence may occur even 10 years after initial treatment. Concluding, imaging radiology well defines extent of tumour. Craniofacial resection combined with chemoradiotherapy is accepted treatment for esthesioneuroblastoma.

A15 Management of patients with non-benign craniofacial tumors D. Zabolotnyi*, O. Palamar Institute of Otolaryngology AMS of Ukraine, Kiev, Ukraine We reviewed 81 patients with non-benign craniofacial tumors over the last 6 years. Mean age 35 years. Histology mostly presented with sinoparanasal cancers- 41 patients, osteo-chondro tumors (osteoblastoma, chordoma, chondrosarcoma)- 12 patients, vascular tumors (hemangiopericitoma, hemangiosarcoma)- 7 patients and other soft tissue tumors (neuroblastoma, rab-domiosarcoma, angioleyomioma)- 21 patients. We divided our patients into 3 groups: there was 25 primary patients (surgery followed by radio and/or chemotherapy), 27 secondary patients (cra-niofacial resection preceded with radio/ chemotherapy) and 29 patients who were referred to us because of failure to control local tumor growth. They received craniofacial resection. In the last group the disease anamnesis was 33–52 months unlike in the first two groups when the anamnesis lasted less than a year. We conclude that initial radio/chemotherapy followed with craniofacial resection was most effective way for the sino-paranasal cancers and less effective for the other pathologies (vascular, osteo and other soft tissue tumors) where the initial surgery followed with the radio/chemotherapy turned out to give better results. Overall we received 3-years survival in 60% patients and 5-years survival in 30% patients. Decrease twice took place mostly over vascular and osteo patients with longer anamnesis.

A16 Maxillary atrophy: onlay bone grafting and sinus lift P. Martinez-Seijas1*, J. Arruti Gonzalez, R. Lobato Perez, U. Bolinaga Zubizarreta, N. Perez Martin 1 Hospital Donostia San Sebastian, Spain Objectives: We present the management the sequelae in maxillary atrophy patients and the maxillary sinus surgical management. Materials and methods: We discuss their treatment of the pronounced lower jaw protrusion and alveolar atrophy do not increased the sinus pathology. Results: We present representative case in maxillary surgery with onlay bone graft and bilateral sinus lift. Conclusions: The goals of treatment are to reduce Class III a normal Class I relationship, adding bone graft for endosteal implants and finally the dental prosthesis. We do not find an increase sinusal pathology with these surgical techniques.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158

A17 Modified blair and face lift incisions in parotid surgery: the risk of facial nerve dysfunction M. Shakeel1*, A. Al-Adhami2, A. Trinidade1, A. Canna2, A. Hussain1 1 Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK; 2School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK Introduction: The face lift incision is aesthetically superior to other types of incision. The facelift approach provides at least equal access to all regions of the parotid gland when compared to a Blair’s incision. Objective: To assess the safety of face lift incision by establishing the incidence of post-parotidectomy facial nerve paralysis. Study design: Retrospective chart review. Ethics: Clinical Effectiveness department. Method: During 1996–2007, 192 patients underwent parotidectomy at our tertiary referral centre. Data were collected on demographics, clinical presentation, site of lesion, pathological diagnosis, type of parotidectomy, type of incision and post-operative complications. SPSS v 16 was used for data collection and analysis. Results: There was equal gender distribution with a mean age of 53 years (4–84). Out of 192 patients, 69% underwent complete superficial (CSP), 30% had partial superficial (PSP) and 2 had total parotidectomy (TP). Modified Blair’s incision was used in 56% of cases (80 CSP, 27 PSP and 1 TP) and 44% had a face lift (52 CSP, 31 PSP and 1 TP) approach. The incidence of transient facial nerve paralysis was 30% with modified Blair’s incision compared to 19% with face lift incision. However, this difference was statistically insignificant (P = 0.09, Chisquare). When stratified by parotidectomy type, the association was only significant for PSP where the face lift incision was favoured (P = 0.02, Chi-square). No permanent palsies were encountered. Conclusion: When compared with the Blair’s incision, the face lift incision is not associated with an increased risk of post-operative facial nerve dysfunction.

A18 Myxoma of the maxillary sinus in childhood C. Gantas, E. Gletsou, P. Pavlidis, C. Makrypides, E. Theos, C. Evaggelopoulos, V. Lachanas*, T. Apostolidis Otorhinolaryngology, Head and Neck Surgery Department, School of Medicine, University of Thessaly, Larissa, Greece Myxomas of the paranasal sinuses are benign, but locally invasive neoplasms that rarely appear in the skeleton. When myxomas occur in osseous sites, they are found almost exclusively in the jaws. They are usually related to dental malformations or missing teeth, but may also not be associated with such abnormalities. They usually affect adolescents and young adults, and very rarely affecting people before 10 years of age or after 50 years of age. We resent the experience of our department in maxillary myxomas in children. Two boys 16 months and 20 months old referred to our department complaining of a bulging in the right maxillary region. There was no report of trauma in the past. Complete clinical examination including nasal endoscopy was performed as well as CT and MRI of the paranasal

1043 sinuses which showed a mass in the maxillary sinus infiltrating the anterior wall of the right maxillary sinus in both cases. The mass was removed through a transoral approach in the 16-month-old boy and through lateral rhinotomy approach in the second boy. The pathologic examination revealed myxoma of the maxillary sinus in both cases. No additional therapy was given and there were no recurrences after 3 years of follow-up. Myxomas are locally invasive, but benign tumors with difficulties in pathological diagnosis and tendency to recur, thus long term follow-up is strongly recommended.

A19 Orbital pathology: meeting point R. Lobato1*, P. Martinez Seijas, N. Perez, U. Bolinaga, J. Arruti, G. Diaz Basterra 1 Hospital Donostia San Sebastian, Spain Introduction: The diagnosis and management of the orbital disorders remains a challenging field within maxillofacial surgery and overlaps with opthtalmology and neurosurgery. Materials and methods: A brief review of the pathology that can affect the different aspects of the orbit: continent and content; the different spread anatomic regions. Usually one divides orbital diseases in five groups: I congenital and development disorders, II traumatic, III inflammatory and infectious (IIIa acute: orbital cellulitis and IIIb chronic: nonspecific chronic inflammation or inflammatory pseutomumor), IV Graves0 orbitopathy and V benign and malignant neoplasm. They can be grouped in five clinical models: I Inflammatory, II mass effect or space occupying lesion, III structural: continent, IV vascular and V functional. Discussion: A wide variety of diseases may affect the orbit. The most common are: Graves0 disease orbitopathy, idiopatic orbital inflammation, orbital cellulitis or abscess, orbital neoplasm (hair and cavernous dermoid cyst, lymphangiomas, neurofibromas, scwannomas, hemangiomas, glioma and meningioma of the optical nerve, pleomorphic adenoma of the lacrimal gland and low and high flow vascular lesions). Conclusions: Occasionally, collaboration of the ophthalmologist, neurosurgeon and maxillofacial surgeon are required for the proper treatment of the disease. Sometimes, intraconal lesions may require different surgical approaches such as orbitotomy or craniotomy. During exploration the position of the ocular globe should be evaluated and the existence of symptoms of orbital apex, superior orbital fissure should be discarded. In order to obtain a pathologic diagnosis FNAC (fine needle aspiration cytology should be considered.

A20 Osteochondroma of the mandibular condyle P. Martinez-Seijas*, U. Bolinaga Zubizarreta, N. Perez Martin, R. Lobato Perez, J. Arruti Gonzalez 1 Hospital Donostia San Sebastian, San Sebastian, Spain Objectives: We present the management of a mandibular condyle osteochondroma with a conservative approach. Materials and methods: We discuss the management of mandibular condyle osteochondroma. Results: We present the clinic case of a woman with asymmetry and overbite. Malocclusion due to a mandibular condyle osteocondroma.

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1044 Conclusions: The study and diagnosis is very important in this pathology. A conservative approach can be useful in a individualized case, in others we need orthognatic surgery.

A21 Osteoma and mucocoele of the frontal sinus M. Zˇizˇic´-Mitrecˇic´, M. Jurlina*, A. Melada, R. Prstacˇic´ KBC Zagreb, Zagreb, Croatia Here we report rare case of the osteoma of the frontal sinus and anterior skull base with consequent mucocoele in a 27 years old patient. The patient presented with visible prominence of the bone in right frontal region, frontal headache and edema of the right supraorbital region and upper eyelid. There were no other ophtalmological symptoms. Diagnostic workup was performed: CT demonstrated hyperdense lesion in right frontal sinus with extension toward upper ethmoid cells and Crista Galli. Cranially and dorsally from previosly described lesion, an expansive lesion of lower intensity could be followed in the right frontal sinus with signs of destruction of the posterior wall of the frontal sinus and intracranial extradural extension. MRI showed hyperdense lesion in T1 and T2 sequences and confirmed inflammatory origin of the lesion. The patient underwent surgical treatment. Bifrontal osteoplastic craniotomy was performed through coronary skin incision. The frontal sinus was entirely occupied with extradural mucocoele of 5 9 6 cm in diameter which was subsequently removed. Osteoma of the anterior cranial base was completely drilled out in a manner of a Lothrop frontal sinus operation. Frontal sinus was obliterated with previously harvested abdominal fat tissue and fibrin glue. The patient is now disease free in a 3 months follow-up.

A22 Osteomas of the paranasal sinuses G. Bjelogrlic1*, V. Stojanovic Kamberovic2, M. Bozovic3, G. Videnovic4 1 Institute of ENT and MF Surgery, Clinical Centre of Serbia, Belgrade, Serbia; 2‘‘Zvezdara’’, Health Center Belgrade, Belgrade, Serbia; 3Medical Center Uzˇice, Belgrade, Serbia; 4Medical school of Prisˇtina, Clinical for MFS, Kosovska Mitrovica, Kosova Introduction: Osteomas, benign mature tumors of the connective tissue, can appear in all paranasal sinuses (PNS), most frequently in the frontal, less frequently in the ethmoid and maxillary, and very rarely in the sphenoid sinus. Objective: To determine the significance of diagnosis and therapy of this disease. Method: Between 2002 and 2007, based on anamnesis, clinical examinations, and radiographic procedures of the PNS, we diagnosed osteomas in 13 patients and we undertook appropriate surgical interventions in seven of the patients, plus a PH analysis. Results: In this 5-year period we diagnosed osteomas in 14 patients, of which one was under 20 years of age, 11 patients were middle aged (84.76%), and 1 patient was over 60. Eight of the patients were male (61.53%). Headaches as the main symptom were present in 46.15%, localized pain in 23.07%, difficulty in breathing

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 through the nose, with dislocation of the bulbus and deformity of the facial bones in one patient, and asymptomatic, during miscellaneous radiology procedures, changes were found in 23.07%. Localization of the osteomas was the most frequent in the frontal sinus in 84.61%, in the ethmoid sinus in 7.69% of the cases. Surgery was indicated in 8 patients, and was performed in seven patients, most frequently osteoplastic operations. Conclusion: In enduring headaches or localized pain, with a rhinological or ophtalmological clinical picture, we should suspect osteomas, benign-slowly-developing tumors, whose symptomatology depends on the size of the compromised surrounding structures. Treatment of choice was a surgical-osteoplastic operation. Keywords: Osteomas, PNS, Diagnosis–therapy

A23 Over-projected nasal tip M. Kirjas1*, E. Obocki2 1 ENT Department, University Clinical Center, Skopje, Macedonia; 2Plastic Surgery Department, Civil Hospital, Skopje, Macedonia Materials and methods: Tip surgery with or without total rhinoplasty has been performed in 35 patients who where admitted at ENT University Clinic in Skopje in the period from 2004 to 2008. Reduction of the projecting tip in these instances presents a problem. In most cases, the dome required to be retro placed, or by removing equal portions of the lateral and medial crura, leaving the cartilage at the dome intact. With these techniques, the anatomy of the dome will not be alliterated. Conclusion: Attention is drawn to the role of the enlarged or prominent anterior nasal spine its relevance to tip projection. In some cases, excision of a large anterior nasal spine alone will suffice for retro-displacement of the nasal tip.

A24 Reanimation of the face after facial nerve palsy: results of over 100 cases treated with a new technique M. Pietniczka-Zaleska1, J. Bien1*, A. Kukwa2 1 Department of Otolaryngology, MSS Hospital, Warsaw, Poland; 2Department of Otolaryngology, Medical University of Warsaw, Poland Objectives: Facial nerve paralysis significantly decreases the quality of life. There are different options for surgical repair of the facial nerve—one of the most effective method is the anastomosis of the distal trunk of the facial nerve with the proximal trunk of the hypoglossal nerve. In order to preserve the function of the tongue we propose our new technique. Methods: 105 patients with facial nerve paralysis of miscellaneous origin had a hypoglossal–facial anastomosis with simultaneous anastomosis of the descending branch of the cervical ansa with the distal stump of the hypoglossal nerve in 101 cases. In 48% patients simultaneously with the neural anastomoses additional gold weight implantation in the upper eyelid was performed. Results: The results showed all patients to have an improvement in their House-Brackmann grade following anastomoses, with 12%

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 achieving grade IV, 30% grade III, 58% grade II, with no evidence of hemitongue atrophy or dysfunction. Conclusion: The new technique anastomosis is a relatively safe procedure, which offers good functional results with no evidence of dysfunction of the tongue. Combination of the hypoglossal–facial anastomosis with simultaneous anastomosis of the distal hypoglossal nerve stump to the cervical ansa and with gold weight implantation provides the advantage of immediate protection against ophthalmic complications, prevents hemiatrophy of the tongue and gives satisfactory facial reanimation results.

A25 Reconstruction of maxillary defects using temporal musculoperiosteal flap E. Salmi*, I. Kinnunen, K. Aitasalo Department of Otorhinolaryngology, Head and Neck Surgery, Turku, Finland Objective: To evaluate the usefulness of pedicled temporal musculoperiosteal flap and free calvarial bone graft for reconstruction of maxillary defects. Methods: 34 patients were operated due to maxillary defects using temporal musculoperiosteal flap with or without free calvarial bone graft. Diagnosis, localisation and staging of the tumours, and used radiotherapy were reviewed. Classification of the maxillary defects was performed according to the Brown et al. (2002) and success rates of the reconstructions were evaluated. Results: 32 patients were operated due to malignant tumour, one due to benign tumour and one for the maxillary defect after trauma. The most common diagnosis in the tumour group was squamous cell carcinoma (n = 15), and the most common localisation was maxillary sinus (n = 14). Majority (n = 22) of the malignancies were of advanced size (TNM classification T3–T4). Preoperative radiotherapy (n = 14), preoperative chemoradiotherapy (n = 2) or postoperative radiotherapy (n = 11) were used in tumour group. Temporal musculoperiosteal flap was used with (n = 21) or without (n = 13) free calvarial bone graft. At 1 month follow-up, flap survival was 71.9%. 28.1% of the patients suffered from partial flap loss and 0% from total flap loss. At 6-month follow-up the flap survival was 76.9, 7.7 and 15.4%, respectively. If unilateral alveolar maxillectomy was performed, at 1 month follow-up the according flap survival was 82.6, 17.4 and 0%, and at 6 months 89.5, 10.5 and 0%. Conclusion: Pedicled temporal musculoperiosteal flap with or without and free calvarial bone graft provides a suitable surgical approach in treatment of maxillary defects.

1045 Method: The patient candidates for close nasal bone reduction (CNR) were divided in to three groups: topical anesthesia (TA), local anesthesia (LA), and general anesthesia (GA) and CNR was performed. After reduction, pain scores, satisfaction, and failure rates after 2 and 30 days were noted. All the patients were followed up for at least 1 month. Results: The average pain scores (TA = 2.35, LA = 2.47 and GA 1.9) showed no significant difference among these three groups (P value [ 0.05). The percentages of patients’ satisfaction in the groups were as follows: TA = 84.6%, LA = 83.8%, GA = 91.7%. These values had no statistical difference (P value [ 0.05). There was no significant difference among the failure rates on the second day and after 1 month of follow up. (After 2 days: TA = 10%, LA = 18% and GA = 14% and after 1 month: TA = 2%, LA = 7% and GA = 5%). Conclusion: If the selection of patients is done properly, CNR under TA/LA will have considerable success in comparison with GA. TA is suggested in simple nasal fracture with unilateral depression or minimal displacement.

A27 Rhinoseptoplasty: form versus function F. Jakimovska*, E. Dimitrovski, B. Dimitrovska University ENT Clinic, Skopje, Fyro Macedonia Rhinoseptoplasty is the most challenging and complicated surgical procedure. The aesthetic features of the face are dominated by the shape of the nose and its degree of harmony with other structures.The cartilaginous septum is the central structural element of the nose. Aim: The aim of the study is to review some of the surgical techniques of the rhinoseptoplasty, to evaluate the nasal airflow and illustrated with patient examples. Materials and methods: All 240 cases underwent rhinoseptoplasty. In 212 of total 240 cases a primary rhinoseptoplasty was performed, whereas in 28 secondary rhinoseptoplasty. Patients divided in 3 groups according to profile and angulatory deformites: hump 105 (44%); scoliotic 99 (41%) and saddle nose 36 (15%). Anterior rhinomanometry was performed preoperative and postoperative in 240 patients. Patients followed up through periods ranging from 3.6 to 12 months. Results: Aesthetic results were graded excellent in 198, good in 25, satisfactory in 17. Nasal flow was graded excellent in 202, good 24, satisfactory in 14. Conclusion: The form and function are virtualy inseparable in rhinoseptoplasty and must be evaluated jointly.

A28 ‘Sail’ excision of alar rim for alar contour surgery A26 Reduction of nasal bone fractures: a comparative study of general, local and topical anesthesia techniques S. Atighechi*, M. Baradaranfar, G. Karimi, A. Mirvakili, H. Dadgarnia, P. Kamiabsharifi Shahid Sadughi Hospital, Yazd, Iran Aim: The present study aims of nasal bone fracture reduction carried out under topical, local, and general anesthesia in order to suggest a proper treatment for nose fracture patients.

E. Yap1* 1 Metropolitan Hospital, Makati City, Philippines A common feature in Asian noses especially of Malay origin is the overhanging ala. Correcting the overhanging ala markedly improve the ‘gull’s wing in flight’ look. It also improves the columellar show. It also gives a counter-rotation look of the tip. Excision can be done either inside or outside the rim. The inner rim excision is most commonly used because this procedure also makes the nostril smaller (a feature of southeast Malay nose is big nostrils). A short video clip will be presented.

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A29 Serial nasal bone reduction: a new approach to the management of nasal bone fracture

Conclusions: Glabbellar and nasolabial skin flaps can be used for reconstruction of the defects of the external nose with a success.

S. Atighechi*, G. Karimi, M. Jabbari Department of Otolaryngology, Yazd University of Medical Sciences,Yazd, Iran

A31 Technologies, techniques and materials in reconstructive surgery of the anterior skull base

Nasal bone fracture is the most common type of facial bone fracture. Although these injuries often do not appear to be severe, under treatment of nasal trauma could lead to significant long-term problems. The post-reduction incidence of nasal deformities requiring subsequent rhinoplasty or septorhinoplasty ranges from 9 to 50% in different studies. A clinical trial study on 330 cases with simple nasal bone fracture was performed. These patients were divided to two groups randomly. In case group, serial nasal bone reduction was performed, and in control group classic nasal bone reduction was performed. The failure rate following the initial reduction in the first visit after reduction was 14.3 and 14.1% in case and control groups respectively, but their difference was not significant (P [ 0.05). After serial reduction in case group (step 3), the failure rate was diminished to 4.19%. It was statistically superior to the failure rate of control group after 1 month of follow-up (14.7%) (P = 0.001). Serial nasal bone reduction could be helpful to diminish the failure rate of nasal bone reduction.

R. Hainarosie*, V. Zainea, I. Postolache, N. Popescu, M. Hainarosie, R. Irina, J. Lazar, C. Octavian, M. Lupascu, M. Criveanu IFACF-ORL, Bucharest, Romania

A30 Surgical treatment of the external nose skin cancer recurrences with simultaneous reconstruction of the surgical defect using local tissues I. Belatsarkouski* N. N. Alexandrov’s Research Institute of Oncology and Medical Radiology, Minsk, Belarus Purpose: The analysis of the results of reconstruction of total surgical defect of the external nose skin after removal of recurrent tumor using glabellar skin flap. Patients and methods: From 2000 to 2004 surgical treatment was applied in 18 patients (8 women, 10 men; age range 39–72 years) with external nose skin cancer appeared during 1–2 years after radiation therapy with total dosage 60–70 Gy (X-ray therapy, electron therapy). All the diagnosis were proved morphologically (11 recurrences of basal cell carcinoma and 7 of squamous cell carcinoma). First group consist of 5 patients with total involvement of the skin of external nose. Among these in 3 cases the only skin involvement (rT3N0M0) existed, in 2 cases the tumor was spred to nasal septum (rT4N0M0). Second group: 8 patients with skin of dorsum of nose involvement (rT2N0M0). Third group consist of 5 patients with skin of the nasal wing involvement (rT2N0M0). The surgery volume consist of excision of the recurrence with more than 1 cm margin and reconstruction of the defect using triangular nasolabial skin flap. Results: In all the groups the healing was by primary intention. In the first group there was a need to perform 2–3 correction surgery during a year for satisfactory aesthetic results. In the second group the excision of tissue abundance in 2–3 months was needed in the region of rotation of displaced flap.

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The aim of the study is to present update techniques and materials used in surgical treatment of the pathology located in the anterior skull base, originating mainly from the ethmoid and sphenoid sinuses. Method consists in selected clinical cases which reveals surgical attitude and comments over the different surgical techniques used by the authors. There are discussed the clinical cases from the last 7 years, 2002–2008, when the authors began their experience concerning the tumors located to the anterior skull base. There are taken into account 62 cases and selected 10 cases to be presented. The authors comment the use of radiosurgery and Argon plasma surgery in some cases and try to establish the correct physical parameters of this technology applied to the pathologic tissue located at the anterior skull base. Duraplasty materials and techniques are also analyzed and commented. The mid term results of using different types of techniques and technologies are critically evaluated.

A32 Temporal branches of the facial nerve and their relationships with the fascial layers S. Turkoglu Babakurban1*, O. Cakmak1, S. Kendir2, A. Elhan2, V. Quatela3 1 Department of Otorhinolaryngology, Baskent University Faculty of Medicine, Ankara, Turkey; 2Department of Anatomy, Ankara University Faculty of Medicine, Ankara, Turkey; 3Quatela Center For Plastic Surgery, Rochester, NY, USA Background: Temporal branches of the facial nerve are endangered during surgery related with midface, temporomandibular joint and temporal region. Despite several studies in the literature, controversy still exists about the nomenclature of the anatomical structures in this region and topographic relationship of the temporal branches of the facial nerve with fascias, fat pads. Objective: To eliminate the contradiction on nomenclature and to describe the topographic relationship of the temporal branches of facial nerve with fascias, fat pads to define a safe surgical approach in this area. Materials and methods: The study was performed on 18 hemifacial cadaveric specimens. 12 facial halves were coronally sectioned and dissected. In 6 hemifacial specimens, level by level planar dissection was done. Results: Temporal branches of the facial nerve coursed along the zygomatic arch as a single, two, three, or four twigs in 14, 57, 14, and 14% of specimens, respectively and they were travelling inside the

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 deep layers of temporoparietal fascia and SMAS. Temporoparietal fascia showed no attachment to the zygomatic arch and continued caudally as SMAS. There were adhesions between the temporoparietal fascia and the superficial layer of the deep temporal fascia around the arch. In the majority of specimens, superficial layer of the deep temporal fascia continued as parotideomasseteric fascia and deep layer inserted on superomedial edge of the arch. Conclusion: Easy and safe approach is to elevate deep to the intermediate fat pad directly on the deep layer of the deep temporal fascia and going down to the periosteum along the zygomatic arch.

A33 The technique of the upper eyelid gold weight implantation in patients with facial nerve palsy after the cerebellopontine angle tumor removal B. Rygalska2, I. Lukawska2, K. Chojnacka2, E. Dziaak2, R. Chmielewski1*, R. Bartoszewicz1 1 ENT Department, Warsaw Medical University, Warsaw, Poland; 2Warsaw Medical University, Warsaw, Poland Surgery of the cerebellopontine angle tumor often causes facial nerve damages and lagophthalmus. There are many methods of eye protection in the case of the facial nerve palsy. The aim of our work is to evaluate the upper eyelid gold weight implantation method. We retrospectively examined the group of 19 patients with the facial nerve palsy after the cerebellopontine angle tumor removal, who had been supplied with upper eyelid gold weight implants, in the years 2005– 2008 at the Central Clinical Hospital in Warsaw. In the study patients medical data and publications were used. We analyzed: age, sex, stage of tumor, degree of facial nerve palsy, surgical technique and complications. In the years 2005–2008 there were 97 surgeries of the cerebellopontine angle tumor. 19 patients (11 women, 8 men) had a golden plate implanted. Mean age was 53.2 years. of this group, 4 cases were operated in T1, 6 in T2 and 9 in T3. In 2 cases the surgery was complicated by the nerve paralysis. In all cases the same surgical technique was used. Size and weight of implants were adjusted individually. In terms of the complications we encountered 1 case of the periorbital hematoma. There were 2 cases of corneal defect and 2 patients had the plate excreted. Golden weight implantation is an effective and safe method of short and long term eye protection in patients with the facial nerve palsy. Plates are easy to implant and remove and give relatively small risk of complications.

A34 The value of selective rehabilitation of peripheral facial palsy I. Stankovic1*, D. Milisavljevic2, M. Stankovic2 1 Clinic for Physical Therapy and Rehabilitation; 2Clinic for Otorhinolaryngology, Nis, Serbia Objective: Patients with facial palsy are not homogenous when neuromuscular dysfunction is analyzed and nonselective therapy has unequal level of improvement after physical therapy. Patients: In order to verify the effects of physical therapy of peripheral facial palsy according to the degree of dysfunction we

1047 performed prospective study of 54 patients divided into four groups: altered initiation of movement, difficulty with facilitation, difficulty with movement control and difficulty with relaxation. Interventions: Rehabilitation of facial palsy included application of physical procedures and training of facial musculature. Main outcome measures: Facial Grading System (FGS) and Facial disability index (FDI) were used for evaluation of treatment. Results: Facial palsy in initial stages evaluated by FGS shows the biggers changes at rest, and during movement, and the smallest values for synkinesis. Later on, better values of FGS at rest, and during movement, but with high synkinesis score are present. Traumatic palsy is characterized by more alterations than idiopathic facial palsy FDI indicates on more physical scale initial alterations, with subsequent domination of social scale changes. Physical therapy resulted in improvement of all the parameters in all the studied groups, compared to the group without such treatment. Reduction of sinkinesis, and improvement of rest status, and facial movements were found, together with better physical and social scale values in all the groups af facial alterations. Conclusion: Selective and individual approach to physical therapy of peripheral facial palsy can have important therapeutical influence if the type and degree of neuromuscular dysfunction are used for selection of therapy.

A35 Unplanned admissions following ambulatory plastic surgery: a retrospective study D. Marev* Departement of Otorhnolaryngology Universiti Hospital ‘‘Sv.Marina’’, Varna, Bulgaria Introduction: Admission for overnight or longer hospital stay from a day-case unit is an unwelcome event. This audit was designed to identify the incidence of unplanned admissions and also to detect the potential factors for such overstays. Patients and methods: Details of plastic surgical day-case patients were obtained from the hospital records for a period of 6 months (February 2004 to July 2004). Results: The total number of unplanned admissions was 28. High rates were recorded in patients above the age of 80 years, male patients and body mass index. Duration of surgery and waiting time in the day surgery unit had significant correlation with the overstays. Grade of the surgeon was not an important determinant factor. of procedures which resulted in an unexpected admission, the most frequent were otoplasty (8.4%) and fasciectomy for Dupuytren’s contracture. Unexpected admissions were also high following rhinoplasty and nipple reconstruction but the total number of operations performed were not significant. Overall, the cause of the overstays were mostly surgical followed by anaesthetic and social. Discussion: With an overall unplanned admission rate of 3.55%, our unit is close to the national standard of 2–3%.Postoperative bleeding was the most important surgical reason for overstays followed by intravenous antibiotics, wound drainage, excessive duration of the procedure and additional, unplanned procedures. Among the anaesthetic factors, postoperative pain was the leading cause (62.5%) followed by nausea, vomiting and adverse anaesthetic reaction. Conclusions: The reasons for unplanned admissions are multifactorial and merit appropriate patient selection and proper estimation of the disease process.

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A36 Upper eyelid gold weight implantation in case of facial nerve palsy: patients satisfaction B. Rygalska2, I. Lukawska2, K. Chojnacka2, E. Dziaak2, R. Chmielewski1*, R. Bartoszewicz 1 ENT Department, Warsaw Medical University, Warsaw, Poland; 2Warszaw Medical University, Warsaw, Poland Facial nerve injuries produce lagophthalmos. There are many different methods used to protect the eye. The most popular is the upper eyelid gold weight implantation that helps the lid to close by the force of gravity. The aim of this method is to protect the cornea and to improve the cosmetic effect. We evaluate patients satisfaction of efficacy, comfort and tolerance of upper eyelid gold weight implants. 10 patients with gold weight implants were asked to fill in a questionnaire by phone. Interviewed patients have facial nerve palsy caused by surgeries of the cerebellopontine tumors carried out in years 2005–2008 in the ENT Department, Central Clinical Hospital in Warsaw. Mean time of implant usage is 10.5 months, shortest 0.5 month, longest 24 months. 5 patients still have implant, one for the second time. Mean degree of the eyeball uncovering in voluntary eye closure is 65% before implantation and 6% after implantation. After the implantation we assessed: tearing—40%, drying of the eye—80%, conjunctival hyperemia—40%, deterioration of visual acuity—30%, eye irritation—70%. None of patients had an ectropion. Efficacy of this method was answered on scale of 1 to 10, and valued for 8.6 points. 70% of patients were satisfied with cosmetic effect after implantation. The gold weight implant is positively assessed by majority of patients. To improve the safety and comfort it is particularly important to use appropriate loading of the eyelid and to refer the patients for regular ophthalmology follow-up. HEAD AND NECK SURGERY

A37 A new view to the relationship of recurrent laryngeal nerve and inferior thyroid artery M. Kulekci1*, A. Batioglu Karaaltin2, I. Uzun3, O. Saatci1 1 Taksim Education and Research Hospital, Istanbul, Turkey; 2Goksun Dr. Sureyya Adanali Hospital, K. Maras, Istanbul, Turkey; 3Turkish Forensic Medicine Foundation, Istanbul, Turkey Objective: Recurrent Laryngeal Nerve (RLN) injury is on of the serious complications of thyroid surgery. Identification of the nerve during surgery is mandatory to decrease the possibility of injury to a state. In this study we aimed to define and classify all the possible relationships between the RLN, Inferior Tyroid Artery (ITA) and its branchs in detail. Method: After obtaining a permission from the directory of Turkish Forensic Medicine Foundation, between January 2007 and April 2007, 100 cadavers with both sides (i.e. 200) were examined for this study, including 81 males and 19 females between the ages of 18 and 90 years at death. Every founding was noted and documented in the form of high-resolution photographs after anatomical dissection. Result: The relationships of both structures and its branchs were classified in to 6 types respectively. Details were verified as relationship between main trunks, trunks and branches and in between the

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 branches respectively. Type A (Ita tr-to-Rec tr), Type B (Ita branches -to-Rec tr), Type C (Ita tr -to- Rec branches), Type D (Ita branchesto- Rec branches), Type E (Ita branches-to- Rec tr and rec branches),Type F (as others). Conclusion: Despite of various anatomical and surgical studies performed previously, in this study we tried to demonstrate simple and easily remembered classifications that might help surgeons to avoid possible injury to the recurrent laryngeal nerve and branches. Keywords: RLN, ITA, Anataomical relationship, Classification.

A38 Actinomyces: does it effect post tonsillectomy outcome? S. Bathala*, P. Puttasiddiah, H. Whittet West Wales General Hospital, Carmarthen, UK Introduction: Actinomyces are known to involve virtually every anatomic site in the body. Since 1896 Actinomyces have been histologically observed in tonsillar specimens with occurrence rate of 1.3 to 37%. Objective: Does colonization of tonsil with actinomyces species effect postoperative outcome of patients undergoing tonsillectomy. Materials and methods: Corec approved single blinded prospective study of 250 patients who underwent elective tonsillectomy at Singleton Hospital Swansea. All the patients were more than 16 years at the time of Surgery. Tonsillar specimens were sent to Histology to identify the presence of Actinomyces. Results: Actinomyces species were found in 162 tonsillar specimens out of 250. Preliminary data suggests a clear relation between colonization of tonsil with actinomyces species and postoperative morbidity.

A39 Actinomycosis presenting as painless neck swelling S. H. A. Primuharsa Putra1, A. Mazita2, W. M. Wan Muhaizan3 1 Ear, Nose and Throat, Head and Neck Consultant Clinic, Seremban Specialist Hospital, Seremban, Malaysia; 2 Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia; 3Lablink, Kuala Lumpur, Malaysia Introduction: Cervicofacial actinomycosis is an uncommon disease caused by Actinomyces species. Cervicofacial actinomycoses are usually painless, slow-growing, hard masses which can produce cutaneous fistulas, a condition commonly known as lumpy jaw. The presentation of a chronic palpable mass and the difficulty in establishing the microbiologic diagnosis makes it difficult to differentiate the mass from a neoplasm, granulomatous disease, or a fungal infection on the basis of the initial presentation. Case report: We present a 31-year-old Indian man who had history of painless right neck swelling for 1 month which gradually increased in size. Clinical examination showed a 3 9 3 cm, firm to hard painless right neck mass. Other examinations were unremarkable. Result: Computed tomography of the neck showed a well defined mass which displaced the sternocleidomastoid laterally. Fine needle aspiration cytology showed histiocytes, leucocytes and occasional groups of epithelial cells. No atypical cells are seen. He underwent excision of the mass. Histopathological examination revealed

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presence of sulphur body consistent with diagnosis of Actinomycosis. He was given oral Sulbactam/Ampicillin for 14 days. On follow-up, there was no recurrence. Conclusion: As this case demonstrated, infection with actinomycosis can mimic a neoplastic process by presenting with a large mass. Without a high index of suspicion, the diagnosis can easily be overlooked. When considering a nodular mass, along with neoplastic processes, the possibility of neck infections with actinomycetes, fungi, and mycobacteria should be entertained.

A40 Adenoid cystic carcinomas of the salivary glands are associated with high-risk HPV A. Albers1*, C. Chen1, M. Hummel2, E. Glastetter3, U. Keilholz4, A. Kaufmann3 1 Department of Otolaryngology, Head and Neck Surgery, Charite, Mitte, Berlin; 2Department of Pathology, Charite, Mitte, Berlin; 3Department of Gynecology, Charite, Mitte, Berlin; 4Department of Hematology and Oncology, Charite, Mitte, Berlin The etiology of adenoid-cystic carcinoma (ACC) is unknown. The only known risk-factor is previous exposure to radiation. Despite surgery and radiation therapy, long-term cure is rare. Therefore, a better knowledge of the etiology could lead to innovative therapeutic approaches. HPV was classified as human carcinogen due to an epidemiologic association with cervical cancer and its ability to induce malignant transformation of cells. HPV was also identified to cause a subgroup of squamous cell carcinoma of the head and neck. 68 ACCs were analyzed retrospectively. HPV-typing was carried out using HPV PCR and multiplex genotyping. Immunohistochemistry was used for P16- and EGFRstaining of 68 ACC 39% were positive for high-risk HPV. of these were 44% HPV16, 15% HPV18, 2.5% HPV or -59 single and 1.25% HPV45 and -33 double positive. 57% were HPV negative or positive for lowrisk HPV11 (4%). The p16-expression was strong in 23.5%, intermediate in 20%, low in 8% and in 36% positive in single cells. EGFR was strong in 27%, in 13 % intermediate, in 14.5% low, in 5.5% positive in single cells and negative in 40%. The association of ACC with high-risk HPV defines a subgroup of tumors that is most likely caused by infection with HPV. As in other HPV caused cancers, we also found in ACC as the predominant HPV-type HPV16 followed by HPV18. All highrisk HPV positive ACC showed at least a partial p16 overexpression. The EGFR expression did not correlate with the HPV-association.

A41 Ameloblastic carcinoma of the maxilla: case report and review of the literature 1

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A. Benlyazid *, M. Lacroix-Triki , R. Aziza , A. Gomez-Brouchet2, M. Guichard1, J. Sarini1 1 Institut Claudius Regaud, Toulouse, France; 2 Djavakhishvili State University, Tbilisi, Republic of Georgia Materials and methods: A case of ameloblastic carcinoma of the maxilla arising in a 90-year-old patient is presented with a review of 65 other cases of the international literature that have been compiled.

Results: The median age was 44 years with a predominance of men (42/66). The maxilla was concerned in almost one-third of cases (21/66). Twenty deaths of disease were reported in a median time of 60 months. 15 of them (75%) were due to a metastatic spreading in the lung, the brain or the bones; the others were due to a local recurrence. The specific survival rate was 68.7% at 5 years. Conclusion: Ameloblastic carcinoma is a rare entity of odontogenic tumors that exhibits malignant histologic features in the primary site. Its specific mortality, estimated at 31.3% at 5 years, was generally due to a metastatic spreading which concerned almost one-third of the published cases.

A42 Amyloidosis of the nasopharynx: an unexpected cause of unilateral middle ear effusion N. McCluney, M. Shakeel*, A. Dallas, A. Hussain Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK Objective: We report a rare case of primary nasopharyngeal amyloidosis presenting in an otherwise healthy adult woman as a unilateral middle ear effusion. Methods: Case report and a review of published literature on otolaryngologic manifestations of amyloidosis. Results: Amyloidosis is an idiopathic disease that is characterised by the extracellular deposition of fibrillar proteins. The disease can be categorised as primary, where spontaneous deposits of amyloid occur, or secondary, where deposits occur in conjunction with chronic diseases such as rheumatoid arthritis or tuberculosis. The deposits can be localised or systemically distributed. It can mimic, and also be associated, with underlying malignancy. Potentially serious complications can result if amyloidosis is not considered as a diagnosis at initial presentation. Conclusions: Amyloidosis is a rare cause of a nasopharyngeal lesion, and less so a secondary middle ear effusion. Its association with underlying chronic and malignant disease must not be overlooked if serious implications are to be avoided. It is therefore important to consider this as a differential diagnosis in such patients.

A43 An interesting case of papillomatosis J. Bakk*, E. Fu¨le, I. Fu¨lo¨p, C. Lengyel, K. Szarka Hungarian Society of Oto-Rhino-Laryngologists, Budapest, Hungary This case report wants to present how the benign papilloma can involve more organs step by step (from the larynx till the genitals). Our patient’s first examination was happened because of aphonia at the age of 8 months. She was operated with larynx papilloma many times. At the age of 2, she was operated not only because of laryngeal but pharyngeal papilloma. A year later, the procession stopped in the larynx but appeared in the nasal cavity. Notwithstanding 20 operations and podophyllin local treatment, the procession destructing the external part of the nose, the inferior turbinate and the medial wall of the maxillary sinus, later the nasopharynx, the ethmoid roof and involved the base of skull. In the last few years our patient has a tympanoplasty because the papilloma involved the tympanic cavity

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1050 and filled up the auditory duct. The papilloma was HPV 11 positive. After tympanoplasty she has got Intron therapy. The procession shows regression but for a short time. Meanwhile our patient had a conisation because of HPV inducted in situ carcinoma in the cervix of uterus.

A44 An uncommon complication of coblation palatoplasty S. Healy*, M. Johnston Derby Royal Infirmary, Derbyshire, UK Objective: We report an uncommon complication of palatal surgery for obstructive sleep apnoea. Method: A 41-year-old female nursery nurse presented with a history of daytime somnolence, chronic nasal blockage and snoring. She had an Epworth Sleepiness Score of 17. Following clinical examination she was listed for a septoplasty, coblation turbinectomy and coblation palatoplasty. On review 3 weeks post-operatively she was noted to have an oronasal fistula with some nasal regurgitation of fluids. Her fistula closed with conservative management and her Epworth Sleepiness Score improved to 8. Her snoring however did not resolve completely and she was referred for a mandibular advancement splint. We discuss the options for the management of obstructive sleep apnoea and review the evidence available for the various surgical techniques. Conclusion: A literature search has only identified palatal fistulae following cleft palate repair making this an important case to highlight. It also demonstrates the need for further trials to support the use of surgery in sleep apnoea/hypopnoea syndrome and follow-up of these patients to monitor the long term outcomes of surgery. Medical photographs showing the palatal fistula post-operatively and after spontaneous closure will be included.

A45 Anatomic study of the lateral walls of the sphenoid sinus D. Radeanu* ENT Department, Cluj-Napoca, Romania Within the present study, 60 preserved sphenoid sinuses were endoscopically/classic dissected and the denivelations were analyzed (eminences or depressions) identified with the lateral walls; there were taken into consideration the denivelations made by the internal carotid artery, the optic nerve, the maxillary and vidian nerves. The internal carotid artery has produced a identifiable protuberance at the level of the lateral walls of the sphenoid in 51 cases (85%). The optic nerve was identified upon the protuberance it produced in 35 sinuses (58.3%), while with the rest of the cases—25 cases (41.7%) it could not be accurately identified. The vidian nerve was identified with certainty upon its protuberance at the level of the sphenoid ceiling with only 15 cases (25%) under the shape of a thin eminence on the bone trabeculae. The maxillary nerve could be identified at the base level of the lateral sinusal wall with 16 cases (26.6%), with the majority of the cases simultaneous with the identification of the vidian nerve below it. 1. We set out herein to emphasize the importance of the knowledge of the anatomy of the sphenoid sinus and the links its lateral walls have with extremely important anatomical elements: the internal carotid artery, the optic, maxillary and vidian nerves.

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 2. We underlined the importance of understanding the anatomy of the sphenoid sinus in great detail and the recognition of clinical manifestations of the sinusal or neighboring diseases, and especially for a good development of the endoscopic surgical undertaking.

A46 Anterior craniofacial resection: progress in treatment of patients with the widespread tumours of the nasal cavity, paranasal sinuses and orbit R. Rafik1*, V. Nazim2*, R. Rufat3* 1 Central Railway Hospital, 2Neurosurgical Hospital, 3State Medical University, Baku, Azerbaijan We observed 14 patients with tumors of nasal cavity, paranasal sinuses and orbit extending on anterior skull base and penetrated in anterior cranial fossa (ACF). At 6 patients were benignant, at 8 malignant tumors. Anterior craniofacial resection (ACFR) as standard operation has been applied in all cases; at malignant tumors it was applied in a combination with radio and/or chemotherapy. In 4 cases was available ossifying fibroma of nasal cavity, and in 2 adenoma of eyeball. In one case fibroma involved on fila olfactoria, and in 3 cases a tumor alongside with involving in ethmoidal and sphenoid sinuses penetrated into ACF; at patients with adenoma of the eyeball (2) the tumor penetrated into ACF. Among patients with malignant tumors in 7 was esthesioneuroblastoma, and in one case squamous cell carcinoma. In 3 cases with esthesioneuroblastoma the tumor extended in nasal cavity, ethmoidal sinuses, orbit and cribriform plate; in the others 5 with a tumor in nasal cavity, the tumor extended in ethmoidal sinuses and penetrated in ACF. All benignant tumors have been radical removed; in 2 cases the expanded operation, including exenterating of orbit content. At 2 patients with malignant tumor the operation including enucleating an eyeball. 5 patients with esthesioneuroblastoma had recurrence. With recurrence of 5 years have lived 3 patients and 1 patient with squamous cell carcinoma with this term without recurrence was lived. ACFR provides removal of all benignant tumors penetrating into ACF, and also allows hoping for progress of treatment of patients with malignant tumors.

A47 Antimicrobial therapy in recurrent acute tonsillitis N. Doddi*, R. Rivron Royal Glamorgan Hospital, Llantrisant, UK Objectives: (1) Pain caused by anterior nasal packs during insertion, insitu and removal. (2) Ability of the packs to stop epistaxis; (3) Difficulty of use for the clinician. Design: Prospectively evaluating patients admitted with nasal packs for anterior epistaxis using a questionnaire reflecting the objectives of the study. Setting: Royal Glamorgan Hospital, a District General Hospital Participants: 59 patients with recurrent acute tonsillitis who already had a course of Penicillin V or Erythromycin. Main outcome measures: Subjective perception of pain was measured on a visual analogue scale of 0–10, 0 being the least painful. Haemostatic ability of the pack was graded on a scale of 0–3 where 0 is significant bleeding needing further intervention. Difficulty of use was graded on a scale of 0–10 where 10 is the most difficult.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Results: 59 patients with recurrent acute tonsillitis, who did not get better on PenicillinV, were given a 10-day course of Co-amoxiclav. Patients allergic to penicillin were given Metronidazole along with Erythromycin. They were advised to get back to us if there was no improvement in the severity of symptoms or frequency of attacks. 37 (62%) of them did not return to us after 18 months. Conclusions: Antibiotics like Co-amoxiclav that cover beta-lactamase producing organisms and anaerobes along with Group A betahaemolytic streptococci are more effective in treating recurrent tonsillitis than Penicillin V.

A48 Association between transforming growth factor b1 genetic polymorphism and response to chemoradiotherapy in HNSCC P. Mattila*, M. Lundberg, A. Ma¨kitie, L. Aaltonen Helsinki University Central Hospital, Helsinki, Finland Purpose: Transforming growth factor b (TGF-b) is a pleiotropic cytokine that has diverse roles in cancer. Rate of production of the major isoform, TGF-b1, is linked with rs1982073 single nucleotide polymorphism in TGFB1 gene signal sequence. Our aim was to evaluate the influence of this genetic polymorphism on survival of patients with head and neck squamous cell carcinoma. Material: Peripheral blood DNA of 175 head and neck squamous cell carcinoma patients were genotyped using real-time PCR and fluorescent probes. of the patients 58 had laryngeal cancer, 45 oral cancer, 33 oropharyngeal cancer, 30 hypopharyngeal cancer, 7 nasopharyngeal cancer, and 2 had a cancer with an unknown primary. The median follow-up time was 2.9 years (range 0.8–15.9 years). Results: Patients with the high-producer TGFB1 genotype had a better disease-free and overall survival. This appeared to be confined to patients who had received chemoradiotherapy. Interaction analyses of the 175 patients revealed that among the 38 patients who had received chemoradiotherapy, the high-producer TGFB1 genotypes CC and CT were associated with a better disease-free and overall survival as compared with the low-producer TT genotype (hazard ratios 3.42, 95% CI 1.12–10.5 and 3.09, 95% CI 0.96–10.0, respectively). Conclusion: Genetic polymorphism of the TGFB1 signal sequence is associated with the response to chemoradiotherapy in head and neck squamous cell carcinoma. TGFB1 genetic polymorphism may be used as a clinical marker to predict the outcome of chemoradiotherapy. Further studies are warranted to confirm our results in other patient populations.

A49 Benign myoepithelioma of the parotid gland: case report G. Terzakis, M. Artopoulos*, A. Vafiadis, D. Terzakis, G. Papazoglou Korgialenio-Mpenakio (Red Cross) Hospital, Athens, Greece Myoepithelioma is an uncommon benign tumor of the salivary glands, composed almost exclusively of myoepithelial cells. It accounts for only 1.5% of all tumors in the major and minor salivary glands.

1051 A 29- year-old man presented in our department with a history of progressively increasing swelling in the left parotid region for 7–8 months. On physical examination, the swelling was 2 9 2.5 cm, well defined, firm, mobile, and non-tender. Skin appeared adherent to the swelling. and no cervical lymphadenopathy was noted. An ultrasound tomography of the left neck showed a mass, 2 cm in the largest diameter in the superficial lobe of the parotid gland, with well-defined margins. The patient had already done an FNAC and the results were positive for a benign myoepithelioma of the parotid gland. The patient underwent left superficial parotidectomy under local anesthesia. Histopathologic and immunohistochemical examination revealed the same diagnosis with the FNAC. The patient today is free of disease. There are only rare case reports of preoperative fine needle aspiration cytologic (FNAC) diagnosis of myoepithelioma of the salivary gland. Surgical excision of the tumor is the treatment of choice with excellent results.

A50 Bilateral synchronous inverted papilloma of the nose and paranasal sinuses case report M. Jurlina*, M. Zˇizˇic´-Mitrecˇic´, R. Prstacˇic´ ENT Department, Clinical Hospital Center, Kisˇpatic´eva 12, Zagreb, Croatia The inverted papilloma is an uncommon benign, usually unilateral, sinonasal tumor of vague etiology. The most prominent clinical symptoms are nasal obstruction and hyposmia usually combined with headache and sometimes with epistaxis. Advanced cases can also present with symptoms of adjoining regions (orbit and central nervous system). This case report has objective to present an unusual case of synchronous bilateral IP of nasal cavity and paranasal sinuses combined with huge osteoma of frontal sinus in a 22-year-old male patient referred to our Department in December, 2002. Endoscopic polypectomy, ethmoidectomy and maxillary antrostomy on the left side, together with septoplasty were performed in March, 2003. In January 2006, osteoplastic operation of the frontal sinus after Lothorp was performed. In October 2006, endoscopic peace meal resection of the recurrent disease on the anterior skull base was performed and underlying bone was completely drilled out. Patient is now disease free at 22-months regular follow up.

A51 Blow out fractures at our department J. Bakk*, I. Bartku, I. Fu¨lo¨p Hungarian Society of Oto-Rhino-Laryngologists, Budapest, Hungary Blow out fractures are caused by direct trauma to the globe which causes an increase in intraorbital pressure and decompression via fracture of the orbital floor. Clinical symptoms are haematoma in the lids, facial hypaesthesia and diplopia. At our department the maxillar fractures are treated with anterior wall osteotomy and Foley catheter fixation. The ophtalmologyst pull up the muscle (m.rectus inferior) or narrowed orbital fat through a transconjunctival incision. We put a Foley catheter into the sinus through the inferior turbinate and fill up with sodium chloride. The balloon has to stay in the sinus for a week and hold the fracture-ends and the orbita contents in place. In our cases this operation technique is successful. The hypaesthesia and diplopia has broken off in every cases.

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A52 Calcificated mass in the great pectoral muscle myocutaneous flap in the neck P. Kalitova1*, M. Urbanova1, J. Plzak1,2,3, J. Betka1 1 Department of Otorhinolaryngology and Head Neck Surgery, 1st Faculty of Medicine, Charles University, Faculty Hospital Motol, Prague, Czech Republic; 2Institute of Anatomy, 1st Faculty of Medicine, Charles University, Prague, Czech Republic; 3Center of Cell Therapy and Tissue Repair, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic Nowadays 72 years old man, former heavy smoker, underwent total laryngectomy, partial pharyngectomy, bilateral neck dissection and reconstruction by myocutaneous flap from the great pectoral muscle and adjuvant radiotherapy for a locally advanced pharyngolaryngeal squamous cell carcinoma with skin invasion pT4pN2bM0 13 years ago. 12 years after the surgery the patient presented slowly growing stony firm mass in the myocutaneous flap in midline of anterior neck. There was a redness of the overlaying skin and small areas of skin destruction showing white firm base with inflammatory secretion from undermined margins. It was difficult to obtain any material for histopathology, but it excluded malignancy and showed calcified fibrous tissue. CT scan showed a calcification 38 9 14 9 22 mm in the anterior part of the neck with very tight relation to the esophagus. Secondary finding was advanced atherosclerosis of all carotid arteries with a complete obstruction of the right internal carotid artery. Since there was a high risk of esophagus damage during attempt of surgical resection and very difficult healing in the irradiated area with very poor blood supply was anticipated, we decided to perform antiinflammatory and local supportive conservative therapy. Gradually during 6 months necrosis of skin cover happened and all calcified mass 5 9 3 cm sequestrated. Definite histopathology confirmed dystrophic calcification. After 6 months the wound re-epithelized. The lesion was classified as a dystrophic calcification in necrosis of myocutaneous flap in irradiated area with worsening of blood supply due to advanced atherosclerosis of the carotid arteries. Supported by NPV 2B06106.

A53 Can NMDA receptor-antagonists reduce aminoglycoside-cochleotoxicity? P. Pavlidis1,2,3*, V. Nikolaidis1, H. Gouveris3, S. Metaxas1, V. Danielidis4, D. Kouvelas2 1 Department of Otolaryngology, School of Medicine, Aristotle University; 2Laboratory of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece; 3 Department of Otolaryngology, School of Medicine, University of Thessaly, Larissa, Greece; 4ENT Department, Demokrition University of Thrace, Alexandroupoli, Xanthi, Greece Objective: The otoxic effects of aminoglycosides, such as amikacin, are well-established. A number of different hypotheses have been proposed to explain the ototoxic effects of aminoglycosides. One of

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 these suggests that aminoglycosides are excitotoxic and produce degeneration of the cochlear outer hair cell through the activation of NMDA receptors. The aim of the present study was to investigate possible limitation of amikacin’s cochleotoxicity when memantine, an NMDA-receptor antagonist, is administered. Materials and methods: Eighteen rabbits were studied. Fourteen animals received intramuscularly amikacin twice-daily every day for 2 weeks. These animals were divided in two groups (groups A and B) of seven members each. The animals of group A received orally memantine every 2 days and animals of group B were not given any memantine at all. The remaining four animals were used as control group (group C). In all 18 rabbits Distortion Products Otoacoustic Emissions (DPOAEs) were measured every 3 days since beginning of the injections. Two measurements (7 and 14 days) were obtained following the cease of drug administration. Results: Reduced cochlear activity (as depicted in the respective reduced DPOAE-amplitudes) compared to the pre-treatment state was found in both groups A and B. Cochlear activity was reduced at a greater range of frequencies in group B than in group A. Conclusion: The findings suggest that the combination of the NMDA-receptor antagonist memantine with amikacin can reduce the cochleotoxic effects of the latter.

A54 Carotid-esophageal fistula after benign esophagic stricture treatment in a 25 years old laryngectomized patient A. Bore´s*, B. Martinez*, E. Rioja, J. Guilemany, A. Obando, F. Marin˜o, M. Rusiecka, J. Blanch, M. Bernal-Sprekelsen Hospital Clinic De Barcelona, Barcelona, Spain Introduction: Carotid esophageal fistula is an uncommon but lifethreatening complication of benign esophageal strictures. We report a rare case of benign esophageal stenosis after a total laryngectomy for laryngeal cancer, which developed massive hemorrhage secondary to a carotid esophageal fistula after laser surgery and esophageal stent placement. Case: A 17-year-old female diagnosed of schamous glottic carcinoma underwent total laryngectomy, bilateral functional neck dissection and complementary radiotherapy. Seven years later she experienced aphagia for actinic esophagical stenosis that was treated unsuccessfully with laser CO2. A pharyngeal–esophagical stent was placed by retrograde esophagoscopy through a previous gastrostomy. Ten days later she presented massive hematemesis. A Sengstaken catheter was placed to stop local bleeding. Emergency arteriography showed a carotid-esophageal fistula at the region of left primary carotid artery. We controlled bleeding by placing an endoluminal stent in primary and internal carotid artery. Five days later the patient presented a second massive hemathemesis, so an embolization of left external carotid artery was performed. Fibrogastroscopy identified active bleeding from the distal end of esophagic stent, which was extracted. A second esophageal stent was placed over the bleeding area. Two weeks later she presented a new esophagical stenosis and necrosis of traqueostomy. She underwent a total esophaguectomy and a thoracical traqueostoma with resection of three necrotic tracheal rings. Currently she has gained weight and receives total intake through a permanent gastrostomy. Conclusion: Carotid esophageal fistula, after esophagical stent is a rare but potentially mortal complication in patients with multiple cervical surgeries and radiotherapy.

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A55 Case report: unusual anastomosis of recurrent laryngeal nerve M. Rudes*, D. Prgomet, S. Janjanin KBC Zagreb, Zagreb, Croatia A 69-year-old woman was admitted to the ENT clinic for surgical treatment of papillary carcinoma of thyroid gland. She presented with symptoms of non-productive cough, difficult expectoration and painless anterior neck mass. Thorough diagnostic analysis was performed in another hospital. Detailed ENT examination revealed painless right side neck mass. Ultrasound of the neck detected 28 9 25 mm node in inferior pole of right thyroid lobe and ultrasound guided FNA cytology of the suspicious lesion was positive for papillary neoplasm of the thyroid gland. Patient was then referred to the ETN clinic for further operative treatment. Classical thyroidectomy approach technique with ultrasound knife assistance was used. After the surgical dissection of the right thyroid lobe and inferior thyroid artery, unusual direct anastomosis between the right recurrent laryngeal nerve and cervical part of vagus nerve was exposed. Knowledge of topographic anatomy and variations of recurrent laryngeal nerve is extremely important in thyroid and parathyroid surgery, laryngeal surgery and oncologic surgery and its implementation in clinical practice significantly reduces complications and postoperative morbidity.

A56 Case report for multiple form of eosinophilic granuloma in 36-year-old man D. Markovski*, K. Dzambazov, D. Vicheva, A. Petkova UMBAL Eosinophilic granuloma (EG) is a benign tumor-like condition which is characterized by a clonal proliferation of Langerhans-type histiocytes and defined as a local form of Langerhans cell histiocytosis (LCH). The radiographic appearances of EG are quite different depending on the phase of the disease and the site of involvement. Involvement of the temporal bone is relatively rare and initially silent. However, it can erode the mastoid cortex, destroy the tegmen and extend into the cranial vault, as well as erode the semicircular canals or cochlea. This is a case report of 36-year-old man with clinical appearance of reduced hearing from left ear, dizziness, nausea, and vomit. Computerized tomography of the skull at that time showed an osteolytic defect in the right temporal bone filled with soft tissue, and also affecting the occipital bone, the floor of left frontal cranial cavity and the bones of calvaria. Diagnosis was established by preformed craniotomy and histological result confirming eosinophilic granuloma, multiple form.

A57 CD105 expression in glottic laryngeal squamous cell carcinoma E. Zvrko1*, A. Mikic2, L. Vuckovic1 1 Clinical Center of Montenegro, Podgorica, Serbia; 2 School of Medicine, University of Belgrade, Belgrade, Serbia

1053 Background: There is increasing evidence that CD105-assessed microvessel density (MVD) can be considered an indirect marker of neo-angiogenesis and important prognostic marker in a variety of malignancies. The aim of this study has been to analyze the expression of CD105 in laryngeal squamous cell carcinoma (SCC) localized in glottic region. Methods: Forty patients who underwent complete excision of glottic SCC were included in this study. Surgical specimens were immunostained for CD105 and MVD was calculated at 4009 magnification. The rounded mean value of the vessel count in four fields for each case was used as the final MVD value. Clinicopathologic data were collected retrospectively. Results: MVD varied among tissue samples from 5 to 21 (median 12.5). The mean MVD assessed by CD105 in considered glottic SCC was 12.3 (standard deviation = 3.65). MVD was significantly higher in patients younger than 66 years than in a group of elderly (P = 0.02). The mean CD105+ MVD values were significantly higher in T3–T4 tumors (P = 0.001) and those in an advanced TNM stage (P = 0.009). Kruskal–Wallis test identified significant relation between pT stages and CD105-assessed MVD (P = 0.011). The mean CD105- assessed MVD were 15.25 and 11.6 in laryngeal SCC with and without malignancy recurrence, respectively (P = 0.023). Conclusions: Our data suggest that CD105-assessed MVD may represent an additional prognostic factor in patients with glottic squamous cell carcinomas providing more accurate data to identify patients at risk of loco-regional disease recurrence.

A58 Cervical emphysema after total laryngectomy and functional bilateral cervical asset stripping: a case report R. Corrales Milla´n*, P. Santos Acosta, C. Lo´pez Ladro´n Garcı´a de la Bobolla, S. Sa´nchez Go´mez Otorinolaringology Department of The Virgen Macarena Hospital, Seville, Spain Background: Case report and review of cervical subcutaneous emphysema after total laryngectomy surgery. Methods: Patient with T3 N1 M1 scamous cellular carcinoma less diverse presented a subcutaneous emphysema 7 days post total laryngectomy and functional bilateral cervical asset stripping. It begun in left submandibular area. Two hours later it spreaded to the left temporal area affecting preocular soft tissues. There was not any infection event clinically nor in the blood test. CT scan highlighted a extensive emphysema in left neck area dissecting subcutaneal level and deep muscle level. In front of digestive track and on top of the traqueostomy appears lineal imagines with hipodense centre, they could be little collections, the biggest in closer relation with left ECM. Results: A direct drainage across the left functional cervical asset stripping under local anesthesic was performed. A minimal traqueostomal suture dehiscent was observed and resutured. This manoeuvres resolved the cervical emphysema and no other complications appeared. Conclusions: Cervical subcutaneous emphysema is an exceptional event in the postoperative course of total laringectomies. A minimal traqueostomal suture dehiscence must be systematically looked forward. Reduced surgical approach under local anesthesia is enough to solve the event.

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A59 Cervical lymphangioma in adults: Description of two cases L. Sgambatti Celis*, J. Gomez Gonzalez, A. Munoz Herrera, F. del Rey, R. de la Fuente, J. del Pozo Hospital Clinico Universitario De Salamanca, Salamanca, Spain Objective: Describe two cases of cystic lymphangioma in adults. Methods: We describe the clinical and pathological features of cystic lymphangioma diagnosed in two adults with lateral neck mass, one man of 45 years old with a right cervical tumor with size of 8 9 7 cm and woman of 58 years old with a right cervical tumor with size of 5 9 5 cm, MRI/TAC and fine-needle aspiration cytology were performed. Results: All patients were treated under surgical excision of tumor, the follow-up after 2 years show no evidence of recurrence. Conclusions: Cervical lymphangiomas are unusual lesions that are believed to develops as a result of a congenital malformation of the lymphatic system, is an uncommon entity, usually reported in children they are often present at birth and diagnosed mostly (90%) before the age of 2 years. Less uncommon in adults are often associated to infection, tumors or trauma. Surgery is indicated. Complete removal is more easily achieved in adults than in children. Recurrences are thus more frequent in adults

A60 Cervicofacial actinomycosis: case report S. Andric Filipovic1*, Z. Petrovic1, V. Djordjevic1, V. Nesic1, A. Ugrinovic1, I. Boricic2, N. Tomanovic2, V. Djukic, J. Milovanovic 1 Institute of ENT and Maxillofacial Surgery, Belgrade, Serbia; 2Institute of Pathology, Belgrade, Serbia Objective: The objective of this paper is to present an cervicofacial actinomycosis. Actinomycosis occurs approximately 50% of the time in cervicofacial region. It is rare disease mainly presented as indurated mass-like lesions. The workup, etiology,clinical presentation and differential diagnosis will be discussed. Methods: A case report and review of literature. Results: A 40-year-old man with 6 months history of dysphagia, odynophagia and snoring. He had 20-pack-year smoking history. Medical history included tonsillectomy (10 years ago) but excluded diabetes mellitus, history of immune deficiency, steroid use. Physical examination revealed unilateral mass at left oropharynx. The 4 9 4 cm left side mass was firm, nontender. A MRI of the neck and pharyngs showed soft tissue enlargement of both tonsils (residual tissue), more on the left side, adhesive to the tongue and associated with cervical adenopathy. The patient underwent unilateral tonsillectomy. Histopathologic evaluation revealed chronic inflammation and presence of actinomyces. Conclusions: Cervicofacial actinomycosis should be taken into consideration in the differential diagnosis of the head and neck masses. It is usually mass like lesions but can be misdiagnosed as other infections or even neoplasms. It is unusually accompanied with regional lymph node enlargement. The diagnosis of actinomycosis depends on the presence of sulphur granules in the exudate, on the culture, and on the hystologic examination of the biopsy specimen. Treatment consists of surgical remove of masses and long term use of antibiotics.

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A61 Change in quality of life in children after surgical intervention for obstructive sleep apnoea/adenotonsillar hypertrophy M. Shakeel*, C. Cardemo, K. Ah-See Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK Introduction: Adenotonsillar hypertrophy is a common occurrence in early childhood which affects quality of life. These children may have obstructive sleep apnoea along with other obstructive symptoms. Adenotonsillectomy is an established intervention for this condition. Objective: To measure any change in quality of life in children undergoing tonsillectomy ± adenoidectomy for symptoms of adenotonsillar hypertrophy and/or obstructive sleep apnoea, using Glasgow Children Benefit Inventory. Patients and methods: Retrospective hospital case notes review over 4 years (2002–2005). The data collection included demographics, indication of surgery, main operation, other operations, surgical technique and post-operative recovery. The Glasgow Children Benefit Inventory (GCBI) was posted to the parents of these children along with a stamped return envelope. The data were collected and analysed using excel and SPSS. Results: A total of 251 patients were identified. The GCBI was posted to all. Seventeen were excluded as the patients had moved with no forwarding address available. The response rate was 40.2% (94/234). There were 54 male and 40 female children. The mean age was 5.3 years (range 1–13 years). Forty-five percent of children had simple Adenotonsillar hypertrophy, 45% had OSA and 10% had OSA along with a history of recurrent tonsillitis. The average total score was 39.4 with evidence of improvement in all four subscales: physical health—66, emotion—18, learning—32 and vitality—49). Discussion and conclusion: Our results are comparable to the published literature. This study confirms sustained improvement in children’s quality of life and validates adenotonsillectomy as an appropriate treatment for adenotonsillar hypertrophy.

A62 Changes in emotional state of snoring and obstructive sleep apnea patients’ bed partners following the radiofrequency tissue ablation V. Uloza1*, T. Balsevicˇius1*, R. Sakalauskas2, S. Miliauskas2, N. Zˇemaitien_e3 1 Department of Otolaryngology, Kaunas University of Medicine, Kaunas, Lithuania; 2Department of Pulmonology and Imunology, Kaunas University of Medicine, Kaunas, Lithuania; 3Department of Preventive Medicine, Kaunas University of Medicine, Kaunas, Lithuania Objective: To asses the influence of Radiofrequency Tissue Ablation (RFTA) on primary snoring and Obstructive Sleep Apnea (OSA) patient’s bed partners sleepiness, anxiety and depression. Materials and methods: 36 bed partners, of primary snoring and mild to moderate OSA patients, including 28 women and 8 men from 21 to 60 (mean 40.58 ± 10.60) years old completed Epworth Sleepiness Scale (ESS), Beck Depression Inventory (BDI) and

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Spielberg’s trait-state anxiety inventory (STAI) before and after the patients’ treatment. The major patients’ symptoms: snoring, disturbed sleep, observed apnea, hyper somnolence and cognitive impairment were evaluated using Visual Analog Scales (VAS). All the patients passed full night complete polysomnography [mean apnea/hypopnea index (AHI) = 13.16 ± 10.76] and were treated with 2 sessions of RFTA. Preoperative and postoperative means of the AHI, VAS, ESS, BDI and STAI were compared using paired Student t tests with confidence level a = 0.05. Results: Patients’ AHI scores improved from 13.16 ± 10.76 to 10.69 ± 8.28 postoperatively (P \ 0.05). Marked improvement in patients complains from their bed partner’s position were observed after two sessions of RFTA. The pre- and post-operative mean VAS scores improved significantly for all measured complains (P \ 0.001). The remarkable changes in patients’ bed partners depression scores were observed. BDI scores improved from 12.69 ± 7.66 to 9.17 ± 6.88 points (P \ 0.005) while ESS and STAI scores remained unchanged. Conclusions: RFTA is an effective treatment of primary snoring and mild to moderate OSA. Treatment with RFTA improves severity of depression in bed partners’ of primary snoring and OSA patients when measured with the BDI (P \ 0.005).

A63 Changes in IGF-I, IGFBP-3 and GHRELIN levels after adenotonsillectomy in children with sleep disordered breathing ¨ nal1 M. Gu¨mu¨ssoy1, S. Atmaca1*, B. Bilgici2, R. U 1 Department of Otolaryngology, Ondokuz Mayis University School of Medicine, Samsun, Turkey; 2 Department of Biochemistry, Ondokuz Mayis University School of Medicine, Samsun, Turkey Objective: The aim of this study was to determine the changes in insulin-like growth factor-I (IGF-I), insulin-like growth factor binding protein-3 (IGFBP-3) and ghrelin levels following adenotonsillectomy (T&A) in children with sleep disordered breathing (SDB). Methods: Forty children (mean age 4.85 ± 2.15 years) clinically diagnosed with adenotonsillar hypertrophy (ATH) related SDB were enrolled. All children underwent T&A. Serum levels of IGF-I, IGFBP-3 and ghrelin were measured before and 6 months after T&A. Results: Mean serum levels of IGF-I and IGFBP-3 were increased significantly after T&A from 94.3 ± 52.9 to 154.3 ± 79.9 ng/ml and from 3.4 ± 1.1 to 4.1 ± 1.2 lg/ml respectively (P \ 0.001). Serum ghrelin levels were decreased significantly after T&A from 2,186 ± 314.9 to 1,703.8 ± 327.5 pg/ml (P \ 0.001). Discussion: ATH, the most common cause of SDB in children, is associated with failure to thrive and reduced nocturnal GH secretion. IGF-I reflects daily mean GH levels and correlates well with the physiologic changes in GH secretion. IGFBP-3, a carrier protein that binds most of the circulating IGF-I and increases its half-life, also correlates well with nocturnal GH secretion. Our findings support the assumption of increased nocturnal GH secretion with increased peripheral IGF-I and IGFBP-3 levels following T&A in children with ATH related SDB. Ghrelin, secreted from the stomach, is an important regulator of growth hormone release and energy homeostasis. Plasma ghrelin levels are decreased in obesity or after acute oral food intake. Stimulation of appetite by ghrelin is independent of GH. In light of our findings, T&A in ATH related SDB yields a significant increase in growth markers indicating an increase in diurnal GH

1055 secretion and a significant decrease in ghrelin levels indicating increased caloric intake. To our knowledge, this is the first study to assess IGF-I, IGFBP-3 and ghrelin levels simultaneously in the same cohort of ATH related SDB.

A64 Changing indications for adenotonsillectomy in paediatric age group and quality of life assessment S. Kumar*, A. Qayyum, T. Wilson, N. Bhat Peterborough & Stamford Hospitals NHS Trust, Cambridgeshire, UK Objectives: Review of practice of adenotonsillectomy and to assess quality of life following surgery. Methods: Retrospective study of paediatric patients (\15 years) undergoing adenotonsillectomy from 1 July 2005 to 30 June 2007 at a district general hospital. Results: Review revealed changing trends for adenotonsillectomy: sleep disordered breathing (71%), recurrent tonsillitis (29%). All patients showed significant improved quality of life scores at 3, 6 and 12 months. Conclusions: There is greater recognition of conditions causing sleep disordered breathing. Surgery was followed by significant improvement in the quality of life.

A65 Child soft palate embryonal rhabdomyosarcoma: case report K. Stankovic*, V. Subarevic, I. Baljosevic, R. Simic Pediatric ENT Center, Mother and Child Health Care Institute of Serbia, Belgrade, Serbia We present a case of 10-year-old girl, gipsy nationality, with very rare localization of the rhabdomyosarcoma of the soft palate. She has been treated in Pediatric ENT Department at the Mother and Child health care Institute of Serbia ‘‘Dr. Vukan Cupic’’ in Belgrade. After CT/ NMR diagnosis and histopathological verification of the embryonal rhabdomyosarcoma botryoid type, we performed radical excision of the tumor which has been located of the soft palate only. Other local structures of the oral cavity were not affected. Postoperatively she was treated with chemotherapy and radiotherapy. After 24 months there was no local recurrence of the disease and metastasis. The aim of this study was to present a patient with very rare localization of rhabdomyosarcoma on soft palate which was successfully treated with surgery.

A66 Children temporal bone rhabdomiosarcoma: literature review and case report R. Martinkiene*, M. Gutauskas, G. Reklaitiene, V. Sakalinskas, S. Stankeviciene, V. Vaivockaite* Vilnius University Children Hospital, Vilnius, Lithuania

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1056 Objective: This case concerns a boy 3 years old who came to our clinic complaining about having headaches in left side of his head and ear pain at the night time for 2 weeks. CT scanning and MRI imagining showed a soft tissue mass. The diagnosis was established by a biopsy. Treatment consists in surgical removing and chemotherapy associated to radiotherapy. Method: Case report and world literature concerning pediatric temporal bone rhabdomiosarcoma. Results: Childhood rhabdomyosarcoma is fast-growing, highly malignant soft tissue tumor of skeletal muscle origin, accounts approximately 5–15% of all neoplasm’s in children. The head and neck are the most common sites of involvement, accounting to approximately 50% cases of pediatric rhabdomyosarcoma. Less than 10% of these tumors begin in the temporal bone. Natural history of rhabdomyosarcoma temporal bone is of highly aggressive, locally destructive, and invasive lesion with high propensity for central nervous system involvement and distal metastatic spread. Because treatment is usually directed at chronic otitis media, the interval of symptom onset to diagnosis averages almost 8 weeks and may be delayed for up to 6 months. After biopsy or removal of the tumor, all patients need chemotherapy. Conclusion: Rhabdomiosarcoma is an aggressive pediatric malignancy. Physician need to have a very high degree of suspicion for neoplastic lesions whenever a child does not improve after treatment, or has ear pain out of proportion or unrelated to infection. Importance of early diagnosis is emphasized with the report of a rare case of temporal bone botryoid type rhabdomiosarcoma.

A67 Clinical analysis of microsatellite instability in patients with head and neck squamous cell carcinoma with other primary sites A. Hisao1*, Y. Hideo1, I. Akira2, I. Hiroyoshi1*, K. Makoto1, N. Aki1 1 Department of Otorhinolaryngology, Graduate School of Medicine, Osaka City University, Osaka, Japan; 2 Department of Molecular Mechanisms of Biological Regulation, Graduate School of Medicine, Osaka City University, Osaka, Japan Background: It is reported that patients with head and neck squamous cell carcinoma (HNSCC) frequently develop other primary cancers, such as esophageal cancers and gastric cancers. Mutations and epigenetic changes affecting mismatch repair (MMR) genes such as hMSH2 and hMLH1 are known to cause microsatellite instability (MSI), which was discovered in studies of hereditary non-polyposis cancer (HNPCC) and subsequently observed in sporadic cancers, however, the relationship between MSI and HNSCC is still unclear. Patients and methods: We examined MSI in 50 patiets with HNSCC. Twenty seven patients had other primary site cancers. Results: The proportion of MSI-positive cases with other primary sites cancers was higher than that of those without them (P = 0.0310). In the cases having other primary site cancers, the interval of incidence between head and neck and other primary sites of cases with high-frequency MSI (MSI-H) tended to be shorter than that of the others (P = 0.100). Conclusions: Since HNSCC patients with MSI-H may have a high frequency of other primary site carcinomas, their screening examinations, such as PET and upper gastrointestinal fiberscopic

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 examination,should be performed at shorter intervals than those of the other patients.

A68 Coblation versus traditional tonsillectomy: a double blind randomized controlled study R. Barati, M. Omrani1*, O. Navid, H. Ebne-alshahidi, A. Ebne-alshahidi, M. Ghoreishi 1 Sadi Hospital, Felezi Bridge, Isfahan, Iran Background: Coblation tonsillectomy is a new surgical technique and needs more research to be known as suitable and standard method for tonsillectomy. Aim: This study aimed to measure benefits and complications rate of coblation and traditional tonsillectomy procedures. Study design: Prospective double-blind randomized controlled trial. Methods: Operation time, intraoperative blood loss, postoperative pain, days taken to return to normal diet and activity and postoperative hemorrhage was compared between 31 subjects who underwent coblation tonsillectomy with 33 underwent traditional tonsillectomy. Results: Significant differences were found in operation time (P \ 0.02), intraoperative blood loss (P [ 0.02), postoperative pain (P \ 0.000), days taken to return to normal diet (P \ 0.000) and normal activity (P \ 0.000). But postoperation hemorrhage (P [ 0.5) was not significantly different between two groups. Conclusion: This study showed a significant lesser incidence in postoperative morbidity and complications of coblation in compare to traditional tonsillectomy. Coblation was associated with less pain and sooner return to daily diet and activity. These results address coblation tonsillectomy as a suitable method to be used instead of traditional method.

A69 Comments concerning a ‘lifetime evolution’ of a nasal polyposis case to malignant tumor of the sinuses and skullbase C. Stoica*, V. Zainea, R. Hainarosie, I. Postolache, M. Hainarosie, I. Rosu, O. Ceachir Institute of Phono-Audiology and Functional ENT Surgery ‘‘Prof. Dr. D. Hociota’’, Bucharest, Romania The aim of the paper is to present ‘lifetime evolution’ of a nasal polyposis case to an extensive and invasive malignant tumor of the sinuses and skullbase during 22 years. The method consists in a clinical selected case. The videocontact endoscopy data and CT scan support the diagnosis and evolution. The results The effect of radiotherapy is commented. The reconstructive facial surgical procedure after removing a remnant externalized tumor, following previous surgery and irradiation is applied and discussed. Conclusion point out the idea that during 22 years of evolution a long lasting process of methaplasia of respiratory epithelium took place. This shows the possibility of transforming normal respiratory epithelium in nasal polyposis, then into an inverted papilloma and then into malignant tumor and the importance of ‘follow-up’ for patient with recurrent nasal polyposis.

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A70 Comparison of curative effect derived from three types of vector-mediated RNA interference targeting polygene in laryngeal carcinoma and nasopharyngeal carcinoma C. Chen1*, T. Zezhang*, C. Shiming* 1 Department of Otolaryngology Head and Neck Surgery, Wuhan, China Nowadays, the most commonly vectors used to deliver siRNA are plasmid, adenovirus and lentivirus. In order to compare the curative effect derived from these three types of vector-mediated RNA interference targeting hTERT-VEGF-BCL-xL, we construct these three vectors containing the antisense of the targeting genes: hTERT,VEGF and BCL-xL. After transfecting Hep-2 and CNE cells with these three vectors, transfective rate, apoptosis rate and cell proliferation inhibitory ratio are detected. Transfective rate is observed by fluorescence microscope; apoptosis rate is analyzed by flow cytometry; cell proliferation inhibitory ratio is detected by cck-8 kit. All of these three vectors are successfully transfected into Hep-2 and CNE cells, the transfective rate of lentivirus and adenovirus are higher than plasmid (P \ 0.05). According to the results, the apoptosis ratio derived from lentivirus-mediated RNAi is higher than another two interventions at 96 h after transfection (P \ 0.05). Also,between 48 h and 96 h,cell proliferation inhibitory ratio derived from lentivirus-mediated RNAi is higher than another two ways (P \ 0.05). In summary, all of these types of vector-mediated RNA interference targeting hTERT-VEGFBCL-xL can achieve effective anti-tumor indications. Lentivirusmediated RNA interference have a higher transfective rate and a longterm curative effect.

A71 Comparison of questions concerning the ORL-HNS-related academic knowledge used at different levels in the education of ENT-specialists in Germany T. Eichhorn*, M. Noack Des Carl-Thiem-Klinikums, HNO-Klinik, Cottbus, Germany Since many years medical students in Germany have to pass their final examination in a written form to become a graduate. Multiplechoice-questions are used for this purpose. Besides ORL-HNS the examinations includes questions of many other medical subjects. The questions of the examination are published later on. Last year in Germany there has been published a list of nearly 1000 questions which can be used at the National Board for physicians after their 5 years residency. Usually this examination is an oral one. For setting a first step of standardization—up to now there does not exist one— the German Scientific Society of ORL-HNS intended that the collection of these authorized questions should establish a first form of manual for this examination which could be used by the examiners. In the present paper the questions of these two examinations which are used for quite different levels in the education of a specialist in ORLHNS are compared. We try to find out if the difficulty of the questionpools for the two examinations really reflects the different purpose for what they are used. If we find out that there are not enough

1057 differences in difficulty we are going to elaborate some proposals how to deal that problem.

A72 Congental parotid gland fistula with marginal mandibular nerve palsy Z. Mahfudz1, S. H. A. Primuharsa Putra2, R. Ramli3, A. R. Arif4 1 Ear, Nose, Throat-Head and Neck Consultant Clinic, Kedah Medical Centre, Alor Setar, Malaysia; 2Ear, Nose, Throat-Head and Neck Consultant Clinic, Seremban Specialist Hospital, Seremban, Malaysia; 3Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Malaysia, Kuala Lumpur, Malaysia; 4 Kedah Medical Centre, Alor Setar, Malaysia Introduction: We report a rare case of congenital ectopic orifice of parotid gland with marginal mandibular nerve palsy. Case report: A 35-year-old man was presented with recurrent serous discharge from his right angle of the jaw. He also has congenital right marginal mandibular nerve palsy. A computed tomography (CT) with fistulography was performed. Result: There is a congenitally ectopic orifice of the right parotid gland with absent of its internal orifice. Patient underwent right superficial parotidectomy and excision of the cutaneous parotid duct / orifice. Postoperative recovery was uneventful. Conclusion: In such cases, pre-operative imaging with sialography is helpful for exact delineation of the ductal anatomy.

A73 Correlation between histopathological minor prognostic factors in laryngeal and pyriform sinus carcinoma M. Chirila*, S. Bolboaca, M. Cosgarea, E. Tomescu UMF, Cluj-Napoca, Romania Objective: To investigate the correlation between perineural, lymphatic and vascular invasion in patients with squamous cell carcinoma of the larynx and pyriform sinus. Study design: Prospective study of patients with laryngeal and hypopharyngeal squamous cell carcinoma who underwent total or partial laryngectomy. Methods: Patients with squamous cell carcinoma of the larynx and pyriform sinus who underwent laryngectomy between 2002 and 2006 in the ENT Clinic of Cluj-Napoca, Romania, were investigated for perineural, lymphatic and vascular invasion and if there exist a correlation between those minor factors on disease-free survival. Results: The present study included 396 patients. The mean diseasefree survival of patients with or without perineural invasion of the minor nerves was statistically significant (P = 0.000102). The mean diseasefree survival of patients with or without lymphatic invasion was statistically significant (P = 0.000000). The mean disease-free survival of patients with or without vascular invasion was statistically significant (P = 0.000021). It was no correlation between the three minor prognostic factors on their effect on disease-free survival. Conclusion: Perineural, lymphatic and vascular invasion influence independently the disease-free survival.

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A74 Correlations between the pharyngoscopy results and apnea–hypopnea index in patients with obstructive sleep apnea syndrome

equipment, and of course, by the difference in professional knowledge level of the surgeons. In our work the basic results of the given comparative analysis are stated. We hope that this analysis will contribute to standardize concepts in otology to facilitate a safe, efficient, and effective standard of care for our patients.

A. Neagos1*, G. Muehlfay2, M. Pacurar3 1 ENT Department, Emergency County Hospital, Tg. Mureo, Romania; 2University of Medicine and Farmacy, Tg. Mureo, Romania; 3Orthodontic Department, University of Medicine and Farmacy, Tg.Mureo, Romania

A76 Development of clinical pathways and operatingtheatre-reorganisation in ENT-hospitals

The recent studies have demonstrated the fact as the therapeutical results in the patients with obstructive sleep apnea syndrome are in close relationship with the correct stadardization. In order to establish a more exact diagnosis in these patients with this pathology there have been introduced numerous methods with subjective and objective examinations which values are closely related to the clinical data comparing them with the polygraphical or polysomnographical ones. Performing the pharyngoscopy during sleeping, correlating the reached date with the apnea–hypopnea index, the desaturation index and the pharyngoscopy results in awaking period, represent the evaluation key of the oro- and hypopharyngeal modifications which are the most often implicated into the obstructive sleep apnea syndrome. The pharyngoscopy, although being a subiective examination method which depends on the experience of the investigator, constitutes an important element in realizing a correct stadialization of the patients and also in establishing the proper therapeutical way for the patients with this kind of pathology.

A75 Current concepts in otology and ear surgery in Russia: comparative analysis of diagnostic and treatment approaches S. Kosyakov*, J. Rochshektayeva Russia Medical Academy for Postgraduate Education, Moscow, Russia Although the basic principles of ear surgery have already been accepted, there is no scientific evidence on the outcome parameters of the techniques of operations. A lot of trends on this question are described in the literature, however, in daily work practicing doctor has got used to rely on own knowledge and experience. The range of preoperative diagnostic procedures varies and frequently depends on personal preferences of a doctor. In this connection it is extremely difficult to create uniform groups and compare the efficiency of operations performed by different surgical approaches. We made the analysis of opinion among Russia otorhinolaryngologist on the basic questions of preoperative diagnostics, usage of different types of grafts and prostheses by means of a questionnaire. Also we compared the results with the similar survey spent in Europe. Distinctions in opinions of the specialists were traced during discussion of questions concerning the choice of graft for miringoplasty and tympanoplasty, amount of preoperative diagnostics, postoperative care of the patients and terms of control of bone conduction. Making statistical analysis of the survey results we revealed main points of controversy among otologists, which were caused first of all by the lack of technical

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M. Holderried*, A. Bahr, H. Zenner, P. Mauz HNO-Universitaetsklinik Tuebingen, Tu¨bingen, Germany Since the implementation of Diagnosis Related Groups (DRG) ENTHospitals in Germany have to improve treatment quality and reduce treatment costs at the same time. Therefore we analyzed at the ENTHospital of Tuebingen University, Germany the existing pathway from admission to discharge of 100 patients undergoing an elective tonsillectomy. The present process revealed its weakness in ineffective, redundant activities by nurses and physicans, unnecessary diagnostic workup, the insufficient organization of the operatingroom (OR)-schedule, the unacceptable turnover time in the OR and placing materials at disposal for the operations. These are cost drivers without improving treatment quality. We generated a new clinical pathway to avoid redundant activities, made sure that only necessary activities are done in due time and scheduled the patients undergoing a tonsillectomy at the same day of the week and in the same OR. Furthermore we established a beeper-controlled wireless system for calling the patients, approved by automobile industry. In addition we developed a new system to place the materials at disposal for the procedures ‘‘just in time’’. Using the new pathway in 60 patients we avoided redundant activities, reduced the average time for calling the patients to the OR from 5 minutes to 5 seconds, reduced the turnover of patients in the OR from 60 to 40 minutes without reducing operating time and made a staff cut from two to one nurses. Overall we cut the costs for patients undergoing an elective tonsillectomy for about one-third and improved the treatment quality.

A77 Does perioperative level of oxidative stress predict early recurrence of squamous cell carcinoma of oral cavity? R. Salzman1*, J. Tomandl2, K. Kankova3, L. Pacal3, E. Tothova1, Z. Horakova1, R. Kostrica1 1 Department of Otorhinolaryngology and Head and Neck Surgery, St. Anne’s University Hospital and Masaryk University, Pekaøska´ 53, 656 91, Brno, Czech Republic; 2 Department of Biochemistry, Faculty of Medicine, Masaryk University, Komenske´ho na´m. 2, 662 43, Brno, Czech Republic; 3Department of Pathophysiology, Faculty of Medicine, Masaryk University, Komenske´ho na´m. 2, 662 43, Brno, Czech Republic We studied plasmatic level of malondialdehyde (MDA) as a marker of exposure of a cell to oxidative stress in patients with squamous

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 cell carcinoma of oral cavity and oropharynx (OSCC). Specifically, to clarify the prognostic role of MDA as a plasma-based molecular oncomarker. Prospective cohort study comprised a total of 67 patients who underwent primary surgery for OSCC. Plasmatic level of MDA was assessed using liquid chromatography. Out of total 67 patients, 12 were lost to follow-up and were excluded from subsequent analyses. A subset of 13 patients manifested recurrence during 36 months follow-up following the initial surgery while 42 stayed in complete remission (CR). MDA level was significantly increased in the relapse group than in CR group (P \ 0.01). By means of Kaplan–Meier survival analysis, we found that median DFI, respectively OAS, in the group with MDA [ median was 10.2 months, resp. 15.6, in contrast to 18.0 months, resp. 18.8, in the patient group with MDA B median. Post-hoc comparison of these two groups revealed statistical significance- DFI (P \ 0.01), OAS (P = 0.06). Patients with high MDA manifested 9.3 times higher risk of a recurrence than patients with low MDA [38.7%, 95% confidence interval (CI) 27.1–55.1%, vs. 4.2%, 95% CI 0.9– 12.5%, P \ 0.01]. In conclusion, MDA seems very promising diagnostic oncomarker for OSCC. Very low cost of its estimation could make it versatile and easy to use diagnostic tool for identification of patients with high risk of recurrence. This project is supported by grant NR/9200-3 from the IGA of Ministry of Health of Czech Republic.

A78 Dystrophic epidermolysis bullosa presenting with recurrent dysphagia M. Dadgarnia*, M. Baradaranfar, M. Vahidy, S. Mirvakili Department of Otolaryngology, Head and Neck surgery, Shahid Sadoughi University of Medical Sciences, Yazd, Iran Background: Dystrophic epidermolysis bullosa is a rare, inherited, blistering disorder that primarily affects the skin and pharyngoesophageal mucosa. Blistering and scaring occur in response to even minor trauma. Case report: A 44-year-old woman was admitted for severe dysphagia and odynophagia which had progressed over the past week to point where she could swallow nothing. Her disease started in infancy with vesicle and bullae on the body surface and oral cavity, due to minor trauma and healing with scar formation. 2 years ago she developed dysphagia and in imaging revealed esophageal stenosis that patient was hospitalized and treated with dilation. In examination she had multiple depressed white scars in her skin and nail dystrophy and loss, also revealed acute multiple ulcerative lesions in oral cavity. Paraclinic evaluation with barium swallow and fiberoptic esophagoscopy showed esophageal stricture in cervical part and phayngeal condida. She was managed with Nistatin drop, Omeperazol, and Fluconazole. After 2 days she could drink liquids and odynophagia relived. Discussion: The esophagus lined with squamous mucosa is subject to the same type of injury as the skin. In some susceptible patients the trauma resulting from passage of solid or hot food apparently permits the squamous layer to slough off the lamina properia and ulcers and blisters develop. Scar formation ensues and stenosis then develops. The stricture usually occurs in the upper third of the esophagus. Conclusion: Patients’ symptoms may be due to new ulcers and fungal inflammation of cervical esophagus that can relive with medical treatment.

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A79 Early loco-regional recurrence in laryngeal squamous cell carcinoma N. Angouridakis*, I. Konstantinidis, A. Christoforidou*, S. Ouzounidou*, A. Nikolaou, V. Vital ENT Department, AHEPA University Hospital, Thessaloniki, Greece Background: The main prognostic variables of laryngeal squamous cell carcinoma (LSCC) are the location and size of the tumor and the presence of cervical lymph node metastasis. Although nowadays treatment is adequate including both surgical and conventional methods, relapse of the disease is strongly related with poor prognosis. Methods: We reviewed the data of patients treated in our department between 2002 and 2007. From a cohort of 400 patients we eliminated the group that recurred within 12 months. They all suffered short loco-regional recurrence after treatment of a laryngeal squamous cell carcinoma. Their epidemiological and clinical data are analyzed and treatment results are discussed. Results: From the 51 patients, all male, median aged of 65 years (37–78) 72% had a positive family history of cancer. In 2/3 of the cases the location of the primary lesion was glottic and in 6% the base of the tongue was involved. 36% of the tumors were T1, 30% T2, 20% T3 and 4% T4. N1 lymph node involvement occurred in 6% and N2 in 4% of them. Median disease-free period was 7.45 months (2–12). The recurrence was local in 37 cases and in 10 involved cervical lymph nodes. In 8 cases extralaryngeal extension with soft tissue involvement was also observed. Follow up (August 2008, median 28.51 months, 1–70) showed from 47 patients that suffered short relapse (4 were unable to find) 15 alive, 12 of them free of disease. Conclusions: It was impossible to identify prognostic factors for early recurrence in these patients.

A80 Early management of penetrating neck injuries during the violence in Iraq M. Hamza*, U. Albeiruty, A. Mosa Iraqi Board for Medical Specializations, Iraq A prospective study on 52 patients with penetrating neck injuries of both civilian and military personnel was carried out at Al-Yarmouk General Hospital, in order to know their incidence and distribution on the anatomical zones of the neck and the associated damage of the vital structures in the cervical region and their early management. Results: Fifty patients (96.15%) were males. Twenty four patients were in their third decade. Twenty six patients (50%) were injured by shrapnel of explosives, 23 patients (44.21%) by bullets and 3 patients (5.77%) by unknown objects. Thirty six patients (69.23%) were injured at zone 2, 11 patients (21.15%) at zone 3 and 5 patients (9.62%) at zone 1. Twenty nine patients (55.77%) had laryngeal and tracheal injuries. Thirteen patients (25%) had pharyngeal and esophageal injuries. Four patients (7.7%) had recurrent laryngeal nerve injury. Nine patients (17.3%) had vascular injuries; 6 arterial and 3 venous. One patient had vertebral and spinal cord injury. Forty one patients (78.86%) had urgent tracheostomy operations, and 13 (25%) had neck exploration. Six patients (11.54%) treated conservatively. Nine patients (17.3%) have died.

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1060 Conclusions: Male patients at their middle age were the predominant victims either by shrapnel or by bullets. Zone 2 was most commonly affected followed by zone 3 and zone 1. Laryngo-tracheal, pharyngo-esophageal and vascular structures were mostly involved. Tracheostomy and neck exploration were the main urgent operations performed for them. The high mortality reflected the serious nature of these injuries and the need for a shielded collar to protect the neck for people at risk of these injuries.

A81 Effect of Nasal Beclomethasone Spray in the Treatment of Otitis Media with Effusion M. Abtahi, M. Omrani1*, A. Okhovat, R. Kelishadi, B. Barati, M. Hashemi, A. Hasan Zadeh, N. Omidifar* 1 Sadi Hospital, Felezi Bridge, Isfahan, Iran Background: Antimicrobials treatment of otitis media (OM) has reduced some complications, but some of chronic complications, and specially otitis media with effusion (OME), seem to increase. Theoretically the usage of nasal corticosteroid sprays may prevent this problem by reducing the local inflammation around the eustachian tube. So this study aimed to evaluate the role of nasal corticosteroid spray as an adjuvant for the treatment of OME. Methods: In a randomized, prospective clinical trial, 2 groups 46 subjects who had OME were recruited. A questionnaire containing patients’ characters, history, complaints, otologic examinations and the report of tympanometries, was filled for all before and after treatment. We administered a period of amoxicillin and a decongestant for both group and nasal beclomethasone spray only for case group. Results: 35 from cases (76.1%) and 22 (47.8%) from controls had an improvement in their symptoms or the quality of hearing (P = 0.005). Partial remission was the most common finding in 52.2% of the patients in the case group but for control group was (37%) no change (P = 0.024). The higher improvement in the tympanic retraction in the case group was significant (P \ 0.05). A significant better tympanometric result has showed in the treatment of left ear in the patients of the case group (P = 0.038) but not for right ear (P = 0.136). Conclusion: We concluded that the administration of nasal beclomethasone spray as an adjuvant for the treatment of OME not only improved the results treatment but also increased the resolution of symptoms and the patients’ quality of hearing.

A82 Effects of heated humidification on CPAP-related inflammation: an experimental rat model B. Martinez-Vidal1*, R. Farre´2,5, J. Montserrat3,5, M. Torres5, I. Almendros5, F. Aguilar4, I. Vilaseca1,5 1 Otorhinolaryngology Department, Hospital Clı´nic, Barcelona, Spain; 2Biofisica i Bioenginyeria, Medicine Faculty, University of Barcelona, IDIBAPS, Barcelona, Spain; 3Pneumology Department, Hospital Clı´nic, Barcelona, Spain; 4Otorhinolaryngology Department, Hospital de Granollers, Barcelona, Spain; 5CIBER, Enfermedades Respiratorias, Bunyola, Spain Rhinitis is a potential side effect of nasal continuous positive airway pressure (nCPAP). Heated humidification (HH) is regularly applied to

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 treat rhinitic symptoms, but its benefits are controversial and human confounding factors make it difficult to draw definitive conclusions. Animal models could therefore be useful. Objectives: To study the effects of HH as a mechanism that may reduce nasal inflammation during nCPAP application in the presence or absence of an oral leak (OL). Study design: Prospective controlled animal study. Methods: Setting I: 36 anesthetized Sprague–Dawley rats were subjected to no-CPAP, 10 cmH2O nCPAP, and 10 cmH2O nCPAP with 100% HH for 5 h (n = 12 each). Setting II: 33 rats were exposed to nCPAP, nCPAP with a controlled OL, and nCPAP with controlled OL and HH (n = 11 each). The degree of nasal inflammation was assessed by directly evaluating the percentage of neutrophils in the nasal mucosa. Results: Percentage of neutrophils was higher after 5 h of nCPAP compared to the control group (0.96 ± 0.26 vs. 0.27 ± 0.07%; P = 0.017). When HH was applied, the percentage of neutrophils did not differ from that observed in the nCPAP group (P = 0.97). The addition of a controlled OL, did not show significant differences in the neutrophils count compared to nCPAP alone (0.75 ± 0.19 vs.0.83 ± 0.29%; P = 0.70). Moreover, the application of HH to the rat with OL did not change the percentage of neutrophils (1.17 ± 0.37%; P = 0.60). Conclusions: HH applied to an acute rat model of nCPAP with and without a controlled OL does not seem to reduce nasal inflammation.

A83 Empirical antibiotical therapy of acute purulent sinusitis in the ENT-department A. Merkulava*, A. Sakovich Belorussian State Medical University, Minsk, Belarus Antibioticotherapy is the base for treatment of bacterial sinusitis. 330 patients with acute purulent sinusitis were investigated. There were no microbiological analyses results in the time when antibioticotherapy was started. Antibioticotherapy with cefalosporines (3rd generation) was use for 93% patients as initial empirical therapy. But only 31% it was monotherapy and 59% it was combination with metronidazole. Indeed, this combination was more effective, the necessity to change antibiotical drugs took place only in 9% patients versus 22% patients in the monotherapy group. The using of metronidazole helps to suppress anaerobs. The ftorchinolones as start empirical remedies for patients with acute purulent sinusitis were recommended very rare, less then 2% (as monotherapy in all cases). Usually, this antibiotic was used as drug of the second line.There were no situations to change the treatment with levofloxacine as not effective. Empirical treatment of intracranial and orbital complications of acute purulent sinusitis is more difficult task. In our investigation we found out the combination of three antibiotics: cefalosporine (3rd or 4th generation), aminoglycoside and metronidazole, as more often programme of treatment of these cases. The aim of this combination of three antibiotics was to suppress all the possible pathogens not only in paranasal sinuses, but in orbital and intracranial structures. All the patients of this group received surgical treatment.

A84 Endoscopic CO2 laser for supraglottic carcinoma with postoperative irradiation S. Cotulbea*, M. Hoaria Alin, L. Stelian, I. Gheorghe, D. Caius, B. Nicolae Constantin ENT Department Timisoara RO, Timisoara, Romania

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Objectives: Supraglottic cancer is aggressive, with high tendency for nodal metastasis. Early detection and effective treatment is of outmost importance. Methods: Between 1997 and 2007, 57 patients with supraglottic cancer T1N0 or T2N0, have been treated endoscopically with CO2 laser. Patients were selected using videoendoscopical procedures (flexible laryngoscopy, suspended microlaryngoscopy) and CT-scan, MRI and neck ultrasonography. Careful preoperative selection is of outmost importance for clinical outcome. We applied simple epiglotectomy—13 cases, extended epiglotectomy—29 cases, HSL (horizontal supraglottic laryngectomy)—15 cases. All patients underwent postoperative irradiation. 8 out of 32 cases staged initially T2 were restaged to T3 on the basis of partially preepiglottic space invasion demonstrated on final pathology review. Postoperative follow-up was 12–48, average 36 months. Results: Primary site control was maintained in 49 cases (85.96%). Regional control was attained in all cases. All patients who presented local recurrence in the larynx were staged T2N0; total laryngectomy was the salvation treatment. Immediate functional results were very good and good in all cases. Naso-gastric feeding tube was necessary in one case, patient with HSL, for a few postoperative days. The patients presented no tracheostomy dependency, no aspiration pneumonia and an average onset of independent swallowing at less than 2 weeks. Conclusions: Endoscopic CO2 laser surgery appears to be an effective and safe alternative treatment for T1N0–T2N0 supraglottic cancer, with superior oncologic and functional results than the other techniques, requiring short hospitalization, no tracheostomy and feeding tube and providing superior rehabilitative result, with a good quality of life.

A85 Endoscopic transnasal craniectomy (ETC) in the management of selected sino-nasal malignancies: surgical technique and morbidity P. Battaglia1, P. Nicolai2, M. Bignami1, A. Bolzoni Villaret2, A. Bizzoni2, L. Volpi1, A. Pistochini1, P. Castenuovo1 1 Department of Otorhinolaryngology, University of Brescia, Brescia, Italy; 2Department of Otorhinolaryngology, University of Insubria, Varese, Italy Introduction: To critically review endoscopic transnasal craniectomy (ETC) and endoscopic dural repair in the management of selected sino-nasal malignancies. Methods: From April 1996 to October 2008, 182 patients affected by malignant tumors of the sino-nasal tract were treated by pure endoscopic resection at two referral University Hospitals. Starting from 2004, 60 patients underwent ETC, which extended antero-posteriorly from the posterior wall of the frontal sinus to planum sphenoidalis and latero-laterally from the nasal septum to the lamina papyracea (N = 27) or from papyracea to papyracea (N = 33). Duraplasty with a ‘3-layer’ technique was carried out using fascia lata for the intradural and intracranial extradural layers (underlay), and fascia lata or nasal mucoperiostium for the extracranial layer (overlay). Results: The complication rate was 15% (cerebrospinal fluid leak in 8 cases and septic fever in 1). The resected dura was involved by the tumor in 14 (23%) cases. After a mean follow-up of 17.5 months (range: 1–54), 58 (97%) patients had no evidence of disease. The recurrence rate was 3.3% (2/60) and one patient died for disease.

1061 Discussion: The improvement of surgical instrumentation and experience acquired during an 11-year period in the endoscopic management of sino-nasal malignancies have contributed to expanding the indications of this approach. ETC is a safe procedure with an acceptable complication rate, and allows wide resection of the anterior skull base dura, correctly assessing its involvement, and consequently better defining the need for adjuvant treatment.

A86 Epidemiological study of cancer of the larynx A. Christoforidou*, A. Antoniadis, Z. Sapountzi, K. Markou, A. Nikolaou, V. Vital University ENT Department, AHEPA General Hospital of Thessaloniki, Thessaloniki, Greece Introduction: Laryngeal cancer is the most common head and neck cancer (excluding skin cancer). Objective: To review the risk factors for carcinoma of the larynx and to search for any strong relations between the way of life and the family history, with the severity as well as the prognosis of the disease. Patients and methods: This retrospective study was carried out from 1993 to 2008. Enquiries were directed at age, histological type, tumor location, gender, occupation, smoking, alcohol consumption and family history. Results: 1,267 patients were diagnosed with malignant tumors of the larynx. High percentage of laryngeal cancer was observed in males (96%) compared to females (4%), whereas the mean age of the patients was 62 years (range 13–90). The histological type in 1,176 (92.7%) patients was SCC of the larynx, whereas 92 (7.2%) had other types of cancer. The most common location of the tumor was the glottis (59.6%), followed by suppraglottic (33.6%), transglottic (5.7%) and more rarely subglottic (1%) cancer. Increased incidence of laryngeal cancer was found in farmers (27.8%) and builders (22.6%). Smokers (71%) and alcohol consumers (59%) were more frequently affected by the disease. Positive family history was found in 326 patients (25.5%). Conclusion: The conditions and the way of life together with the family history are very important epidemiologic factors for the laryngeal cancer. Their study and analysis are very important, in order to minimise the predisposing conditions and to make a significant prevention of the disease possible.

A87 Epitympanic compartments in new-borne temporal bone A. Maniu* ENT Clinic Cluj-Napoca, Cluj-Napoca, Romania Objective: To study pathways of aeration to different compartments of the new-borne middle ear related with the presence of amniotic fluid. Methods: 65 new-borne temporal bones were dissected end sectioned with surgical otomicroscope. The epitympanic compartments and the anatomy of the atticotympanic diaphragm were studied. The presence of amniotic fluid was noted. The most important details were photographed.

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1062 Results: According to Palva, the most important folds in the middle ear were tensor fold and lateral incudomalleal fold. In the ear with fluid content, it was granulation tissue blocking the tympanic isthmus. In those ears, there were other duplicate folds well represented. Conclusion: The presence of amniotic fluid in tympanic isthmus and posterior pouch may lead to formation of granulation tissue and blockage of the aeration pathways to epitympanic compartments and to Prussak’s space. Blockage of the aeration pathways to the attic may cause the conditions for chronic otitis media and cholesteatoma.

A88 Evaluation of taste acuity in young smokers and non-smokers with electrogustometry and contact endoscopy P. Pavlidis1*, V. Nikolaidis1, A. Anogeianaki2, D. Koutsonikolas2, G. Kekes1, G. Anogiannakis2 1 2nd Department of Otolaryngology, School of Medicine, Aristotle University, Papa, Thessaloniki, Greece; 2 Laboratory of Experimental Physiology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece Background: Nicotine has been recognized as capable of inducing changes in taste functionality in conditions of chronic exposure.The objective of this study was the evaluation of taste acuity in smokers and non-smokers and the differences concerning the shape, density and vascularisation of the fungiform papillae (fPap) of their tongue. Methods: Sixty-two male subjects who served in the Greek Military Forces participated in the study and were randomized chosen. Thirtyfour of them were non-smokers and 28 were smokers. All of the smokers used to hold the cigarette on the centre of their lips. Taste thresholds of the participants were measured with Electrogustometry (EGM). The morphology and the density of their fungiform papillae (fPap) on the tongue’s tip were examined with Contact Endoscopy (CE). Results: There was statistically important difference (P \ 0.05) between the taste thresholds of the two groups. Not all smokers showed elevated taste thresholds. Six (21%) of them showed taste thresholds similar to those of non-smokers. Differences concerning the shape and the vessels of the fungiform papillae between the groups were also detected. Fewer and flatter fPap were found in 22 (79%) smokers. Conclusion: The majority of smokers showed elevated taste thresholds in comparison to non-smokers. Smoking is an important factor which can lead to decreased taste acuity. The combination of methods, such as EGM and CE, can provide useful information about the vascularisation of taste buds and their functional ability.

A89 Expression of Fascin and Ki-67 in squamous cell carcinoma of the oral cavity: clinicopathological and prognostic significance Y. Wang*, Q. Ji, C. Huang, Y. Zhu, L. Zhang, Y. Wu Cancer Hospital, Fudan University, Shanghai, Japan Background: Fascin—an actin bundling protein—induces membrane protrusions and increased cell motility in various transformed cells.

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Overexpression of fascin frequently occurs in various kinds of malignant tumours and is implicated in tumour progression, but the role of Fascin in oral squamous cell carcinoma (OSCC) is still unknown. Purpose: The aim of this study was to explore the expression of Fascin in OSCC by tissue array analysis. Methods: Paraffin sections using tissue microarrays of 84 patients with OSCC were investigated immunohistochemically, to determine the level of expression of Fascin and Ki-67 labelling index in tumor specimens. The role of fascin in OSCC was evaluated by correlation with clinical–pathological parameters. Results: Overexpression of Fascin was significantly associated with regional lymph node metastases (P = 0.037),advanced T stage (T1/T2 vs. T3/T4, P = 0.012) advanced tumor stage (I/II vs. III/IV, P = 0.020), recurrent (P = 0.002), histologic grade (well vs. moderately/poorly, P \ 0.001), muscle invasion in buccal mucosa and tongue cancer (P \ 0.001), and Ki67 (P \ 0.001), but was not associated with age, gender, or distant metastasis. The Ki-67 labelling index was higher (P = 0.023) in tumors with poor histologic grade of differentiation. Fascin and Ki67 overexpression were all significantly associated with a poor prognosis (P \ 0.001). Conclusion: Expression of fascin protein may play an important role in progression of OSCC. Overexpression of fascin contributes to a more aggressive clinical course and suggests the potential of fascin as a new molecular target for therapeutic intervention. Fascin and Ki-67 overexpression were positively correlated. Keywords: Fascin, Ki67, Immunohistochemistry, Oral, Squamous cell carcinoma, Prognosis.

A90 Expression of matrix metalloproteinases (MMP-2 and MMP-9) in laryngeal papillomas and laryngeal cancer U. Virgilijus1, L. Vaiva2, L. Vykintas1*, P. Dalia2 1 Otolaryngology Department, Kaunas University of Medicine, Kaunas, Lithuania; 2Pathology, Institute of Cardiology, Kaunas University of Medicine, Kaunas, Lithuania The matrix metalloproteinases (MMP) are a family of proteolytic zinc-containing enzymes, which are responsible to degrade extracellular matrix components and play an important role in the physiological and pathological remodelling of tissues. They role in the development of malignant neoplasia is under investigation. Purpose: To define the expression of MMP-2 and MMP-9 in the tissue from laryngeal papillomas (LP) and laryngeal carcinoma (LC). Methods: The immunohistochemical expression of MMP-2 and MMP-9 was investigated in specimens taken by endolaryngeal microsurgery from laryngeal papillomas (n = 26) and laryngectomy specimens (n = 30) from invasive laryngeal carcinoma. Expression of MMP-2 and MMP-9 was graded on a semiquantitative scale ranging from 0 to 3 point in epithelium and stroma cells by two investigators; thus, the final score ranged from 0 to 6. The nonparametric Kruskal–Wallis test was used for statistical analysis. Results: Epithelial cells of LP and LC demonstrated significantly (P \ 0.05) higher MMP-9 expression in comparison to MMP-2. Expression of MMP-2 did not differ between epithelial cells from LP and LC, while its expression was much higher in stroma cells from LC in comparison to LP (P \ 0.001). The epithelial expression of MMP-9 was statistically significantly higher in LC specimens in comparison to LP (P \ 0.05). MMP-9 positive epithelial cells were located only in basal layer of LC.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Conclusion: Expression of MMP-2 in stroma and MMP-9 in epithelial cells was significantly higher in laryngeal carcinoma specimens than in papillomas. It indicates necessity of further investigations to define function of MMP in morphogenesis of premalignant and malignant laryngeal lesions.

A91 Extramedullary plasmacytoma of the larynx P. Cmilansky*, S. Straka ENT Department, Faculty Hospital of J.A.Reimann, Holleho 14, Presov, Slovakia Plasmacytoma is an uncommon tumor that arises from malignant proliferation of a type of B-cell lymphocyte. It can develop into 3 clinical forms: (a) multiple myeloma (MM), (b) solitary bone plasmacytoma (SBP). EMP is very rare and 80% of EMP occurs in the head and neck region. We report a case of isolated EMP of the left true vocal fold in a 48-year-old male with a 1-year history of hoarseness. Histopathological examination with immunological staining confirmed diagnosis. Bone marrow, bone, serum and urine studies excluded systemic disease and concluded the diagnosis of EMP. Local control was achieved with radiotherapy. Patient remains under medical observation, because relapses or a generalized plasmacytoma still may appear years later.

A92 Fibrous dysplasia of the temporal bone: case report S. Codreanu*, O. Iosif, M. Mutu, V. Postelnicu, M. Popescu, M. Pahontu, M. Radulescu Institute of Phono-Audiology and ENT Functional Surgery ‘Prof. Dr. D. Hociota’, Bucharest, Romania We present a case of fibrous dysplasia of the temporal bone in a 40-year-old woman who complained of intermittent right hemifacial twitching for almost 2 months. Clinical examination showed an extensive stenosis of the right external auditory meatus with tympanic membrane hardly visible, but normal. Audiometry revealed mild mixed hearing loss in the right ear. Computed tomography demonstrated right temporal bone expansion with both osteolytic and osteosclerotic lesions, large areas of destruction of the internal cortical, at the posterior cranial fossa and sigmoid sinus. The fallopian canal in the mastoid segment seemed narrowed. The patient underwent radical modified mastoidectomy under general anesthesia. The bony structure of the mastoid was deeply disturbed, with large areas of decalcification occupied by soft, spongy and bleeding tissue. The mastoid segment of the fallopian canal was looking like half of a cylinder, spongy and mobile. The spongy tissue was removed almost entirely, preserving the vital structures intact. The patient evolution was simple. The immunohistochemistry analysis established the diagnosis of fibrous dysplasia. The patient is perfectly normal at 6 months after surgery. This disease appears mostly during childhood or adolescence, but our patient was 40 years old and her complaints had begun for 2 months. Facial twitching was the revealing symptom and there were no deformities or pains, which are more frequent in fibrous dysplasia. The clinical, radiologic and intraoperative findings were suggestive for an infiltrative tumor and the diagnosis could be establish only by immunohistochemistry.

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A93 Fine needle aspiration biopsy and facial paralysis: a rare complication M. Lobato*, P. Martinez, N. Perez*, U. Bolinaga*, J. Arruti, F. Esnal Hospital Donostia San Sebastian, Spain Introduction: Warthin’s tumor is the second most common salivary tumor. We present a rare complication in diagnosis of parotid tumours. The FNA is used in diagnosis of neck mases and salivary gland tumours. Clinical case: 68 years old, male patient, presented a painless parotid mass that fluctuate. The clinical diagnosis was a right parotid Warthin0 s tumour. The salivary gland Tc-scintigraphy could demonstrate a right great activity A FNA for cytology diagnosis was realized and after 5 h the patient came back with a VII right cranial peripheral paralysis nerve.The diagnosis was intracyst haematoma. Discussion: FNA of solitary neck masses has become a well-accepted, safe, and cost-effective procedure in the diagnosis of neck masses. Failure to establish an accurate diagnosis may be because of sampling error. In these circumstances, repeat aspiration is suggested, and excisional biopsy may be considered. It is demonstrated a variability of 8% in diagnosis of FNA specimens, with a specificity of 96% and a sensitivity of 97%.7. FNA was most accurate at diagnosing epithelial cysts and epidermoid malignancies. FNA was least effective at distinguishing lymphoid hyperplasia and chronic inflammation from lymphoma. Conclusions: – FNA of solitary neck masses is a procedure in the diagnosis of neck masses. – A needle aspiration biopsy is safer and less traumatic than an open surgical biopsy. – We must avoid FNA in vascular tumours. – HIV-associated lymphoepithelial cysts have become increasingly common, comprising up to 60% of parotid lymphoepithelial cysts and the FNA is used in the diagnosis and treatment.

A94 Floating Harbor syndrome associated with malleus fixation J. Hendrickx1*, K. Keymolen2, B. Desprechin3, J. Casselman4 5, F. Gordts1 1 Department of Otolaryngology, Vrij Universiteit Brussel, Brussel, Belgium;2Centre of Medical Genetics, Vrije Universiteit Brussel, Brussel, Belgium; 3Pediatric Radiology, Vrije Universiteit Brussel, Brussel, Belgium; 4 Department of Radiology, A.Z. St Augustinus Hospital, Antwerp, Belgium; 5Department of Radiology, A.Z. St-Jan AV, Brugesm, Belgium Floating Harbor syndrome is a rare syndrome of unknown etiology, which was first described, by Pelletier and Feingold in 1973. A triad of main features characterizes Floating Harbor syndrome: short stature, expressive speech delay and a characteristic facies. Several other features have been described in the literature, such as a short neck, low birth weight, mild mental retardation, hirsutism, posterior rotated ears with low implantation and celiac disease. Other authors reported that recurrent ottitis media could be present. We present a patient with

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a Floating Harbor syndrome and a conductive hearing loss that persisted after placements of grommet, in which a high-resolution CT scan of the petrosal bone showed a prominent mucosal thinking causing a fixation of the malleus. Due to the fact that this is the first case with an abnormal middle ear anatomy, we started a conservative treatment with hearing aids. Neither the parents nor the child it self, noted any hearing loss. Therefore it is advisable to regularly administer hearing test in children with a syndrome associated with a speech delay, to promptly identify and adequately treat any hearing loss.

treatment. This paper describes our approach. In last 12 years we treated 105 patients with frontal sinus injuries. It is team work, with close colaboration between ENT surgeons and neurosurgeons. In all severe injuries of posterior table and/or damaged frontal recess, cranialisattion is the method of choice. Cranialisation was made in 35 patients. Complications were rare, but severe. In one case we had one early postoperative death, one patient had developed pneumocephalus and two patients had after some years piocelas. In most cases functional and esthetic results are good.

A95 Forestier–Roth–Querol syndrome with ENT presentation

A98 Frontoethmoidal sinus osteomas

F. Chirtes*, T. Balcescu, V. Oprea, D. Baltaru ENT, Army Emergency Hospital Cluj Napoca, Cluj-Napoca, Romania The Forestier–Roth–Querol is an infrequent cause of dysphagia. The condition is often named diffuse idiopathic skeletal hyperostosis (DISH). We report the case of a patient whose only symptoms when admitted to hospital were dysphagia and back stiffness with restricted motion. Radiography of the spine revealed ossification of the anterior longitudinal ligament and prominent osteophytes which caused dysphagia through external stenosis of the lower pharynx and the upper oesophagus. The case report of our patient and pathophysiology of the disease are brought forward with emphasis on preferred examination and therapy setbacks.

A96 Fractured tracheostomy tube in the tracheobronchial tree of a child: a case report and literature review Z. Al-Qudehy1*, Y. Al-Nufaily1, H. Yagi2 1 Dammam Medical Complex, Dammam, Saudi Arabia; 2 University of Al-Khartoom, Khartoum, Sudan Various objects have been reported as foreign bodies in the tracheobronchial tree. However a fractured tracheostomy tube presenting as foreign body in the tracheobronchial tree is rare, and could be potentially fatal. Here we report a 13-month-old boy who aspirated a fractured tracheostomy tube and was only diagnosed after few days, when the patient developed respiratory distress. The fractured tracheostomy tube removed with difficulty through the tracheocutaneous fistula only after enlarging it. We belive and after computerized literature searches that this is the first report from the Arabian Peninsula.

A97 Frontal sinus injuries

M. Lobato*, U. Bolinaga*, N. Perez*, X. Altuna, P. Martinez, J. Algaba Hospital Donostia San Sebastian, Spain Introduction: Osteomas are benign tumors of the paranasal sinuses. The incidence is unknown due to their incidental diagnosis. The most frequent localization is the frontal sinus, the estimated incidence varying from 0.01 to 0.43%. Case report: A 46-year-old man without significant past medical history, who presented a palpebral edema and mucopurulent rhinorrhea on the right side. The ocular motility was conserved. He was treated with antibiotic (ciprofloxacin 750 mg, twice a day for 10 days), triamcinolone i.m and corticosteroid nasal spray. The CT scan showed a calcified right frontal mass with an orbital roof defect. The osteoma was removed by open approach and endoscopic techniques. Discussion: Osteomas grow slowly and rarely cause symptoms, those can be headaches, ocular or neurological complications. The management of these lesions depends on patient symptoms as well as the size and localization. Surgical treatment was recommended if the patient had symptoms. Traditional approach to frontal osteomas was an osteoplastic flap. Nowadays, advances in nasal endoscopy over the last 20 years brings us the chance to use these techniques for the management of frontal tumors. Conclusions: Osteomas are benign neoplasm, they sometimes are asymptomatic and are discovered by chance in X-ray examination. Resection of osteomas of the frontal sinus can be performed with preservation of the natural drainage of the frontal sinus, obliteration can be avoided. Endoscopic sinus surgery has revolutionized the management of frontal sinus disease. However, it has limitations such as the size and localization.

A99 Functional sequalae and quality of life after sentinel node excision versus functional neck dissection in patients with oropharyngeal and supraglottic cancer with clinically negative neck

B. Cizmarevic*, B. Lanisnik, T. Groseta, P. Levart ENT and Maxillofacial Department, UKC Maribor, Maribor, Slovenia

G. Lawson1*, N. Matar1, S. Kesch1, O. Desgain1, M. Remacle1, J. Watelet2, H. Vermeersch2 1 Universite Catholique De Louvain Cliniques De MontGodinne, Louvain-la-Neuve, Belgium; 2Ghent University Hospital, Ghent, Belgium

Frontal sinus injuries are usually severe. In most cases, other injuries of the head are also present. Different approaches are available for their

Introduction and aim: Compare the functional sequalae and quality of life (QOL) in two groups of patients with oropharyngeal or

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 supraglottic carcinoma with clinically negative neck: the first group treated with functional neck dissection (ND) after detection of the sentinel node (SN) (positive node), the second treated with SN resection alone (negative node). Materials and methods: We prospectively included 58 patients. All of them had SN resection. Those with immunohistologically positive nodes had ND. Patients with previous cervical or scapular disease were excluded. QOL was assessed using two questionnaires: QLQ-C30, QLQ-H&N35. Functional sequalae were evaluated using the objective and subjective criteria of Hiroyuki. Assessment was performed at least 3 months after the end of the treatment. Results: 47 men and 11 women were included in the study (mean age 63 years). Twenty (34.5%) had SN resection alone. 38 patients (65.5%) had SN resection followed by ND. 21 patients had bilateral ND and 17 had unilateral ND. Histological lymph node staging showed: 44pN0 (75.9%); 6pN1 (10.3%), 5pN2a (8.6%), 2pN2b (3.45%), 1pN2c (1.7%). In the first group, 50.4% of the patients presented with sequalae. In 3.4% of them, the sequalae were attributed to local complications or radiation therapy. None of the second group patients presented with any impairment. Conclusion: SN detection allows a good staging of neck node involvement while reducing the morbidity related to ND. Oncological results are as good as those with primary ND. It has the advantage of a better QOL and less functional sequalae in patients with negative neck nodes without reduction of survival.

A100 Giant lipoma of the neck E. Theos, V. Lachanas*, C. Evaggelopoulos, C. Gantas, P. Pavlidis, C. Makrypides, E. Gletsou, T. Apostolidis, C. Kourtopoulos Otorhinolaryngology, Head and Neck Surgery Department, School of Medicine, University of Thessaly, Larissa, Greece Lipoma, the most common soft tissue mesenchymal benign tumor, is composed of mature fatty cells and occurs predominantly on the upper back, shoulder and abdomen. It is usually located subcutaneously without infiltrating adjacent tissues. Lipomas may be classified as conventional lipomas, lipomatosis, lipomatosis of nerve, lipoblastoma/lipoblastomatosis, other infiltrating lipomas without a vascular component, angiolipomas, myolipoma, chondroid lipoma, extrarenal angiomyolipomas, extra-adrenal myelolipomas, spindle-cell/pleomorphic lipomas and hibernomas based on the clinical and histopathologic findings. We present a case of a giant lipoma (8.5 9 5.7 9 7.7 cm) of the head and neck region, treated in our institution. The histopathologic examination confirmed the preoperative diagnosis. We briefly review world literature emphasizing on the special histological and clinical characteristics helping in their differentiation. The postoperative course was uneventful, and no recurrence was seen in the followup. A thorough preoperative clinical, radiological and cytological examination should be performed to prevent recurrences due to incomplete removal of the tumor. The difficulty of making a confident differential diagnosis of intramuscular benign lipoma with a low-grade well-differentiated liposarcoma indicates a complete excision.

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A101 Head and neck squamous cell carcinoma associated fibroblasts J. Plzak1,2,3*, K. Smetana2,3, L. Lacina4, B. Dvorankova1, M. Kolar5, H. Strnad5, M. Chovanec1,2,3, J. Betka1 1 Department of ORL and Head and Neck Surgery, 1st Faculty of Medicine, Charles University, Faculty Hospital Motol, Prague, Czech Republic; 2Institute of Anatomy, 1st Faculty of Medicine, Charles University, Prague, Czech Republic; 3Center of Cell Therapy and Tissue Repair, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic; 4Department of Dermatoveneorology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic; 5 Institute of Molecular Genetics, Academy of Sciences, Czech Academy of Sciences, vvi., Prague, Czech Republic Paradigm of existence of carcinoma stem cell has been established in solid tumors and it is based on parallel between tissue stem cells and population of cancer cells responsible for tumor spreading. Normal tissue stem cells require highly specialized microenvironment so called niche that is necessary for the maintenance of their stemness. Disorders of such microenvironment drive the stem cell population to entrance to the process of final differentiation. The positive role of tumor stroma in course of vascularisation of tumor bed has already been well described. The sum of evidence that carcinoma associated stromal fibroblasts exert an important role in cancer progression is enlarged and their participation in cancer stem cell niche formation seems to be highly probable. When coculture normal keratinocytes with head and neck squamous cell carcinoma associated fibroblasts, the phenotype of keratinocytes is heavily altered to resemble cancer cells. Modern analytic technologies such as DNA microarrays analysis indicated differences in production of regulatory factors/ cytokines that significant in biological activity of cancer associate fibroblasts. Nature of these fibroblasts is not well understood yet, but principally they can originate in local mesenchyme under the control of cancer cells. However, they can be also arise from tumor cells undergoing epithelial–mesenchymal transition or in cells formed by fusion of cancer cells with local fibroblasts. Summarizing these data, similarly to embryonic development, mesenchymal–epithelial interaction can play an important role in tumor progression and its management may be a promising future anticancer strategy. Supported by the projects No. NPV 2B06106 and 0021620806.

A102 Head and neck trauma hospital admissions analysis in the ENT Department of the Warsaw Medical University in 2007 R. Chmielewski*, T. Szafarowski*, M. Kowalczyk, K. Klaudyna Zwierzyn´ska, A. Orłowski, A. Bruzgielewicz, K. Niemczyk ENT Department, Warsaw Medical University, Warsaw, Poland

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1066 Introduction: In some of the ENT emergency service patients the severity of the trauma requires the diagnostic and therapeutic procedures to be continued after the admission to the ENT Department. Objective: We carried out the qualitative analysis of the traumatic cases admitted to the ENT Department of the Warsaw Medical University over the year of 2007. The data we gathered will be a valuable resource for improving the ENT emergency services in the future. Methods: We analyzed records of 695 patients after head and neck trauma (155 females and 540 males, of the average age 36,6 years), who were admitted to the ENT emergency service of Central Clinical Hospital in Warsaw from the 1 January to the 31 December 2007. The thorough analysis of the medical records of the 20 patients (average age 36.4 years) who required hospital admission were carried out. Results: In 2007, 2.87% (20 patients) of all traumatic cases were admitted to the ENT Department. The remaining cases were successfully treated in the hospital ENT emergency service. In the ENT emergency service the most common head and neck trauma location were: nose and/or face (85.8%) and ear (4.89%). of the 20 patients admitted to the ENT Department, the most common were: nasal and nasofacial trauma (50%) and laryngo-tracheal trauma (20%). The mean hospitalization time was 7 days. Conclusions: The majority of the head and neck traumatic cases were successfully treated in the hospital ENT emergency service. Less than 3% required a hospital admission.

A103 Hemangiopericytoma as a lateral neck mass U. Bolinaga*, R. Lobato*, N. Perez*, A. Zulueta, F. Gorostiaga, J. Algaba Hospital Donostia San Sebastian, Spain We present the management of a hemnagioperycitoma with a surgery approach. Materials and methods: A 65-year-old woman presented to our ENT department with a left sided neck mass, which she noticed 3 weeks ago, simulating a cervical lympadenopathy. On physical examination, a mass of 3 9 6 cm was palpable along the sternocleidomastoid muscle, firm in consistency, non-pulsatile, well defined. To clarify the nature of the lesion we realized a ultrasonography and a TC scan, which shown a vascular origin tumour. A surgical approach was chosen for therapy, the mass run along the sternocleidomastoid muscle, macroscopically reddish, tightly adherent to the muscle. The tumour was dissected from the sourronding muscle tissue. The pathohistological examination revealed an intramuscular hemangioperycitoma. Discussion: Hemangioperycitomas are a rare hypervascular tumours arising from perycites. They may occur mainly in the musculoskeletal system; but only the 10–15% appear in the head and neck region. Generally it is a low grade tumour and they frequently recur locally and occasionally metastatize. To reach the diagnosis we can use angiography, TC scan and magnetic resonance image most authors recommend to treat with a combination of surgery and radiotherapy, although the last one is discussed, like perioperative embolization. Conclusions: – Hemangiopericytomas are uncommon neoplasms they may arise in the head and neck region. – Clinical diagnosis and and treatment is a challenging task because there are very few detailed reports to think in a hemangyopericytoma while examining a lesion. – The suggested treatment is a combination of surgery and radiotherapy.

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A104 HPV-associated tonsillar cancer is still increasing M. Romanitan1, T. Ramqvist2, T. Dalianis2, E. Munck-Wikland3, C. Romanitan4 1 IFACF-ORL, ‘Prof. Dr. D. Hociota’, Bucharest, Romania; 2 Department of Oncology-Pathology, Karolinska Institutet, Stockholm,Sweden; 3Department of Oto-RhinoLaryngology, Head and Neck Surgery, Karolinska University Hospital, Stockholm, Sweden; 4Central Military Hospital, Bucharest, Romania Purpose: To examine the incidence of tonsillar squamous cell carcinoma (SCC) and the proportion of human papillomavirus (HPV) positive tonsillar SCC between 2003 and 2007 in the County of Stockholm in correlation to data from 1970 to 2002. Patients and methods: All patients (n = 120) diagnosed with tonsillar SCC during 2003–2007 in the County of Stockholm were included in this study. Ninety-eight pre-treatment biopsies were available and presence of HPV DNA and HPV-16 E6 and E7 mRNA were tested by PCR and RT-PCR. Incidence data were obtained from the Swedish Cancer Registry. Data reported from 1970 to 2002 were also obtained for comparison. Results: HPV DNA was present in 83/98 (85%) of the tonsillar SCC biopsies from 2003 to 2007. of the 77 HPV-16 positive tumors, HPV-16 E6 and E7 mRNA were found in 98% of the analyzed cases. The proportion of HPV-positive cancers had significantly increased both from 1970 to 2007 (P \ 0.0001) as well from 2000 to 2007 (P \ 0.01), with 68% (95% CI, 53–81) 2000–2002; 77% (95% CI, 63–87) 2003–2005; and 93% (95% CI, 82–99) 2006–2007. The incidence rate of HPV-positive tumors almost doubled each decade between 1970 and 2007, in parallel with a decline of HPV-negative tumors. Conclusion: Today, almost all tonsillar SCC in the County of Stockholm is HPV positive, and the incidence of HPV-positive cancers is still increasing. The data suggest that we are dealing with an epidemic of a virus-induced carcinoma, and that soon practically all tonsillar SCC will be HPV positive, as observed in cervical cancer.

A105 Human papillomavirus infection in tonsillar cancer in the Czech Republic E. Rotna´glova´1,2*, J. Klozar1, E. Kosˇlabova´1,2, M. Sala´kova´2, E. Hamsˇ´ıkova´2, R. Tachezy2 1 Department of Otorhinolaryngology Head and Neck Surgery of The 1st Faculty of Medicine, Charles University, Faculty Hospital Motol, Prague, Czech Republic; 2Department of Experimental Virology, Institute of Hematology and Blood Transfusion, Prague, Czech Republic Background: The incidence of tonsillar cancer (TC) is raising almost all around the world despite an opposite trend in its well known etiological factors such as tobacco smoking and alcohol consumption. Hence it is necessary to investigate other risk factors. Nowadays, it is well documented that HPV play an important role in the etiology of a subset of head and neck cancers.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Objective: We investigated further the role of HPV in the etiology of TC and attempted to determine markers of HPV infection which can be used for clinical purposes. Materials and methods: Hundred and eight patients with the diagnosis of primary TC and 185 healthy controls were enrolled. The presence of HPV in the tumour tissue and cytological material, detection of HPV-specific antibodies and a clinical follow up has been performed. Demographical data were collected from all subjects at enrollment. Results: The prevalence of HR HPV DNA and also of HPV-specific antibodies was significantly higher in patients with TC than in controls. HR HPV DNA and HPV16 E6/E7 specific antibodies were found in oral lavages and in sera of 68.1 and 85.5 of patients with the HR HPV DNA positive tumors. Patients with HPV positive tumors differ from those with HPV negative tumors in smoking and alcohol habits but not in the number of sexual partners. Conclusion: Our results support the theory that HPV positive TC form an epidemiologically distinct group of cancer and therefore HPV detection appears to be a useful marker for the use in clinical practice.

A106 Hystological and immunohistochemical aspects of the epidermoid tonsilar carcinomas C. Mogoanta1*, E. Ionita1, F. Anghelina1, S. Ciolofan1, I. Ionita1, M. Laurentiu2 1 ENT Department, General Medicine Faculty, University of Medicine and Pharmacy of Craiova, Craiova, Romania; 2 Research Center for Microscopic Morphology and Immunology, University of Medicine and Pharmacy of Craiova, Craiova, Romania The aim is to evaluate hystologically and immunohistochemically the main types of tonsils neoplasm and their presentation stage. Current paper presents a 4 years retrospective study (2005–2008) counting 52 cases of amigdallian neoplasms treated by excisional byopsy in the ENT Clinic of Craiova. The specimens were histologically and immunohistochemically analysed for PCNA, CD 20, CD45RO. Results: The main macroscopic tumoral types were exophytic, ulcerated or infiltrative, while microscopy showed that the most frequent was ulcerated invasive spinocelular epidermoid carcinoma (40%). The epidermoid carcinoma presented cordoned or trabecular architecture with frequent monstrous nuclei and abnormal mitosis. The lymphoid tissue was normal in early stages then affected by a stroma fibro-inflammatory reaction with a numerous T-cells population, showing that in the tumoral stroma the cellular defence mechanisms are dominant. Non keratinised epidermoid carcinomas with a low differentiation degree presented fast local extension through the sub mucosal layer as well as early metastases more than 60% of our cases being diagnosed in the IVth stage (TNM). Those aspects were correlated with the intensity of PCNA expression present in more than 80% of the tumoral cell population in non keratinised epidermoid carcinomas and only in the proliferative basal layer in the well differentiated carcinomas. Conclusions: The tonsil carcinomas represent the most frequent neoplasia of this site (85%) with a higher rate in males over 50 years. The diagnostic is usually late because in the tonsil carcinomas we did not find pre-neoplasic lesions like in other oropharyngeal neoplasms.

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A107 Immunohistochemical expression of FHIT gene in inverted papilloma of the nose and paranasal sinuses M. Bura*, H. Galic´, M. Zˇizˇic´- Mitrecˇic´, I. Botica, A. Pirkic´ University Hospital Center, Zagreb, Croatia Inverted papilloma (IP) is a primarily benign lesion that occurs in the nasal cavity and paranasal sinuses. It is recognized as neoplasm with tendency of remodeling and bone destruction, high recurrence rate and the association with carcinoma. Because of these peculiar characteristics, IP is interesting entity for over a decade. The frequency of recurrence after surgical removal in well designed studies is reported as 12–18%. The frequency of carcinoma in patients with IP is reported to be 5–13%. Considering the close association of these two entities it has been speculated that inverted papillomas might act as precursor lesions for the development of malignant squamous cell carcinoma. The Fragile Histidine Triad or FHIT gene was cloned and shown to straddle the most fragile human chromosome site at chromosome band 3p14.2. The exceptionally large FHIT locus is very frequently altered and inactivated in the most common human cancers and premalignant lesions. The aim of this study was to determine FHIT expression in IP. We analyzed FHIT expression status with clinical parameters as recurrence and malignant transformation. FHIT expression was determined by immunohistochemistry studies in tissue samples from 40 tumor specimens. We found significantly decreased staining for FHIT in tumor specimens from patients with recurrent disease compared to those without recurrence. These findings of loss of FHIT protein expression might indicate that FHIT alternations play an important role in the early events of carcinogenesis.

A108 Incidence of nasopharyngeal carcinoma in Belgrade V. Nesic1, S. Sipetic2, D. Miljus3, S. Stosic1, Z. Petrovic1, S. Jesic1, D. Radaljac4 1 Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre of Serbia, Belgrade, Serbia; 2 Institute of Epidemiology, School of Medicine, Belgrade University, Belgrade, Serbia; 3Institute of Public Health of Serbia ‘‘Dr. Milan Jovanovi Batut’’, Belgrade, Serbia; 4 ENT Department, Hospital ‘‘Dr. M. Marin’’, Loznica, Serbia Background: This descriptive study included new patients suffering from nasopharyngeal carcinoma, NPC (individuals with undifferentiated carcinoma of nasopharyngeal type, UCNT and with squamous cell carcinoma, SCC) from Belgrade, Serbia, whose illness was diagnosed during the period 1991–2005. The aim of this study was to examine the distribution of new NPC patients in Belgrade during this period. Method: Data for the population of Belgrade based on sex and age, were obtained on the the basis of census. During our statistical analysis of data we used raw, specific, and standardized incidence rates, standardized according to the world population. Results: During the observed 15-year period, the number of new NPC patients totalled 118, of which 86 (72.9%) were male and 32 (27.1%) female. The average raw incidence rate of NPC within the

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A109 Infectious mononucleosis in the nasopharynx with a clinical feature of nasopharyngeal carcinoma or malignant lymphoma K. Lee*, N. Lee, S. Lee, S. Huh 1 Department of Otorhinolaryngology-Head and Neck Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea The Epstein-Barr virus(EBV) is a human herpes virus which causes infectious mononucleosis. EBV is also considered as one possible etiological agent of Burkitt’s lymphoma, Non-Hodgkin’s lymphoma, Hodgkin’s lymphoma and nasopharyngeal carcinoma (NPC). Among the English literature, it is rare that EBV infection occurs as a nasopharyngeal mass. We report a case of a 31-year-old male with infectious mononucleosis who presented with sore throat, fever, chill and 4-week history of both nasal obstruction. Endoscopic examination as a diagnostic evaluation identified a nasopharyngeal mass which is clinically considered as nasopharyngeal carcinoma or malignant lymphoma. We performed biopsy, and biopsied tissue was also impossible to distinguish histologically from malignant lymphoma on general appearance of the cells alone.

A110 Influence of gastroesophageal reflux (GER) in chronic sinusitis in pediatric age J. Fejza Bulaj* ENT Department, Tirana University Hospital Center ‘Mother Teresa’ Tirana, Tirane¨, Albania Introduction: It is increasingly suggested that there may be a connection between gastroesophageal reflux (GER) or laryngopharyngeal reflux and chronic sinusitis specially in children. The acid causes sinonasal congestion (swelling), making impossible the sinus discharge and clearance and leading to the chronic sinusitis. Objective: To determine the prevalence of GER in pediatric patients suffering from chronic sinusitis. Materials and methods: In this prospective study 58 children from 7 to 15 year old with chronic sinusitis underwent 24 h Ph monitoring. The control group consisted of 40 children from 8 to 14 year old which underwent the same examination for other reasons. They had not ENT diseases.

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Results: The 24 h Ph Monitoring revealed that 32 children with chronic sinusitis (55%) presented GER, while 26 (45%)resulted normal. In control group 14 children (35%) presented GER and 26 (65%) resulted normal. Conclusions: Both groups presented gastroesophageal reflux but GER rate in children with chronic sinusitis was much higher than GER rate in control group. Gastroesophageal reflux can be a factor in etiology of chronic sinusitis but further studies are necessary to confirm it.

A111 Intraoperative ultrasound in surgery of the salivary gland tumor M. Kordylewska1*, W. Golusinski2, J. Pazdrowski1 1 Department Head and Neck Surgery and Laryngological Oncology, 2Department Head and Neck Surgery and Laryngological Oncology, Poznan University of Medical Science, Poland Background: Sonography of the salivary glands region is well established in the preoperative diagnostic of tumors lesions. Its intraoperative use to localize head-and-neck, salivary glands small tumors, has rarely been investigated to date.Intraoperative ultrasound is of particular significance in determining the exact location of a tumor and its relation to the probable course of the facial nerve and to search for satellite foci of the tumor during reoperation. Aim of the work: The aim of the study was to assess the usefulness of intraoperational ultrasonography in salivary glands lesions. Methods: We applied intraoperative ultrasound to 73 patients who underwent salivary gland surgery (18 malignant and 55 benign tumors), and evaluated the following criteria: intraoperative tumor presentation, comparison between sonographic visualization, and tumor detection by palpation, preoperative sonography, CT scan, and in some cases MRI scan. All lesions were reproducible by intraoperative ultrasound and could be demonstrated in sufficient quality. Results: Fifty-four of the 73 tumors could be identified by palpation preoperatively, all tumors were completely removed- 5 multifocal lesions after pre- and intraoperative ultrasound were removed by near total parotidectomy. One tumor was removed by total parotidectomy extended to the parapharyngeal and retromandibular space. In 34 cases superficial parotidectomy was carried out, in 22 extracapsular resection of the tumor and in 11 total parotidectomy. Conclusion: Intraoperative ultrasound is fast, dynamic and feasible under sterile conditions. Especially in salivary gland surgery with small, non-palpable, multifocal tumors, intraoperative ultrasound supports minimal-invasive surgery.

A112 Intratemporal facial nerve schwannoma: case report O. Iosif1*, S. Codreanu1, M. Mutu1, V. Postelnicu1, M. Popescu1, M. Radulescu1 1 Institute of Phono-Audiology and ENT Functional Surgery ‘Prof. Dr. D. Hociota’, Bucharest, Romania

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 We present a case of facial nerve schwannoma in a 46 years old woman who came to emergency room with left peripheral facial palsy, vertigo and otodynia of the left ear. Clinical examination showed a dull and bulging left eardrum. Audiologic testing revealed severe conductive hearing loss in the left ear. Imaging studies made in emergency showed bilateral abnormal pneumatisation of the mastoid and extensive destruction of the mastoid cells in the left temporal bone. Due to the recent facial palsy we considered this case an emergency of acute otomastoiditis and we opted for surgery. The patient underwent radical modified mastoidectomy. The surgery revealed a tumoral mass of gelatinous tissue in posterior part of the tympanic cavity extended to aditus, antrum and mastoid cells. The facial nerve was destroyed almost completely from the cochleariform process to the inferior half of his mastoid segment. The tumoral mass was removed entirely. Due to extensive destruction of the nerve fibers, the facial nerve function could not be reinstated. The patient had a favorable postoperative evolution. The histological analysis was not conclusive, but immunohistochemistry established the diagnosis of facial nerve schwannoma. Facial neuromas are extremely rare and the vast majority are benign, therefore they are often misdiagnosed. Although these tumors present symptomatically during the early growth phase, the onset of symptoms was sudden in our case, without any previous evidences. The intraoperative aspect of the tumor and the radiological findings were uncommon for this pathology. The diagnosis could be established only by immunohistochemistry.

A113 Inverse relation between surfactant protein-A and symptoms and signs of rhinitis in patients with allergic rhinitis and nasal polyposis D. Yuqin1*, T. Zezhang, K. Yonggang 1 Renmin Hospital of Wuhan University Objective: The aim of this study was to examine if allergic rhinitis and nasal polyposis are associated with the level of surfactant protein-A. Methods: Sinus mucosal biopsies were performed in patients with allergic rhinitis (n = 15), nasal polyposis (n = 21) and controls (n = 10). Immunolocalization of surfactant protein was performed with antibodies to SP-A using streptavidin–peroxidase conjugated method and indirect immunofluorescence method. Blood serums were obtained from three subjects in each group for enzyme-linked immunosorbent assay (ELISA) analysis of surfactant protein-A. Results: By ELISA, AR (n = 15) and NP (n = 21) showed significantly decreased levels of SP-A when compared with controls (n = 10), although these two groups were not statistically significant. Immunohistochemical investigation showed intense SP-A staining in the nasal epithelium of each groups, but weak staining in patients with AR and NP. Conclusion: We report for the first time the expression of SP-A in both diseased and normal nasal mucosa using the indirect immunofluorescence method. There was an inverse relation between surfactant protein-A levels and symptoms and signs of rhinitis in patients with AR and NP. SP-A may play a defensive role in the chronic inflammatory diseases of upper airway. Understanding the exact role of SP-A in the upper airway diseases will help develop novel treatment approaches for sinonasal pathoses.

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A114 Is the use of radiofrequency ultrasonic dissector in tonsillectomy has a beneficial effect over the use of lazar? M. Adnan1 1 Consultant-Millitary Hospital, Taif, Saudi Arabia Objective: Comparison of intra- and post-operative morbidities of the use of radiofrequency ultrasonic dissector with the use of lazar during tonsillectomy in the same patients. Patients and methods: All patients underwent tonsillectomy at Al-Hada armed forces and Aouhod hospitals, during the period January, 2000 to December, 2005 were recruited for the study. Radiofrequency ultrasonic dissector (US) was used in one side and lazar (LZ) was used in the other side of the same patient. Intra- and post-operative blood losses, duration of the operation, in addition to postoperative pain score were recorded. Results: Five hundred and twenty-eight patients were recruited for the study. The mean operation duration was significantly shorter in US group as compared to LZ group (P \ 0.01). Intraoperative blood loss was significantly lesser in US group (P \ 0.001). Post-operative pain score was significantly lower among US subjects (P \ 0.001). No significant difference in postoperative hemorrhage was detected between compared groups. Conclusion: The use of US in tonsillectomy showed a beneficial effect on intraoperative blood loss, duration of the operation as well as post-operative pain over the use of Lazar. Keywords: Tonsillectomy, Lazer, Ultrasonic dissector, Morbidity.

A115 Lemierre syndrome: a case report and review S. Gougousis*, N. Argyriou, K. Karagiannidis, M. Mpantoyraki, G. Kontzoglou General Hospital Ippokrateio Thessaloniki, Thessaloniki, Greece Introduction: Lemierre syndrome is usually caused by an acute oropharyngeal infection in young adults or adolescents previously in good health frequently with secondary septic trombophlebitis of the internal jugular vein complicated by multiple metastatic infections and bacteraemia. The usual organism that causes the disease is Fusobacterium necrophorum but there is evidence that secondary infections and pus collection can occur with organism like Staphylococcus aureus. Lemierre syndrome not so long ago was named as the ‘‘forgotten disease’’; with the morbidity of the disease very high. As a consequence of widespread antibiotic use for the pharyngeal infection the typical course of the disease has changed since Lemierre’s original description. Method: A review of the literature and a case report was seen in our Department in the last year. In our patient the characteristic symptom was a enlarging mass in the right side of the neck which is quite rare in the presentation of the Lemierre’s disease. Conclusions: Diagnosis of the Lemierre syndrome is very unclear because of the variation of the clinical symptoms and the negativity of the blood cultures. Awareness of the syndrome and a high degree of suspicion are needed.

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A116 Level VI lymphadenectomy: the potential risk factor of inadvertent parathyroidectomy during thyroid cancer surgery Y. Wang*, Q. Ji, C. Huang, Y. Zhu, L. Zhang Cancer Hospital, Fudan University, Shanghai, Japan Background and objective: Inadvertent removal of parathyroid glands is a recognised complication of thyroidectomy, especially in maligant cases. and , this may have consequences on the longterm regulation of calcium homeostasis post-operatively. The aim of this study was to evaluate the risk of inadvertent parathyroidectomy (IPE) during thyroid cancer surgery. Method: This was a retrospective study of 418 surgical patients who had undergone unilateral thyroid surgery for malignant thyroid diseases from 2004 to 2007. Clinical and pathological data were collected. The following criteria were used to study the predictive value of IPE: gender, the histological type of thyroid carcinoma, level VI lymphadenectomy (LNDVI), extrathyroidal extension of carcinoma, max diameter of tumor, and the presence of thyroiditis in the thyroid. The risk factors were compared between IPE and no IPE groups. Results: No permanent hypocalcaemia had been observed after surgery in all 418 cases, including 94 (22.5%) cases with IPE. In malignant cases, LNDVI is the only risk factor for IPE (P = 0.02), relative risk = 11.90. There was no statistically significant difference between the IPE and no IPE groups regarding gender, the histological type of thyroid carcinoma, extrathyroidal extension of carcinoma, max diameter of tumor, or the presence of thyroiditis in the thyroid. Conclusion: LNDVI is a strong risk factor for IPE in malignant cases of primary unilateral thyroid surgery. The indication of LNDVI should be handled rigorously. Keywords: Thyroid carcinoma, Parathyroidectomy, Level VI lymphadenectomy.

A117 Lifestyle modification in management of reflux laryngitis: importance and limits A. Voineag*, C. Sarafoleanu, C. Manea Withdrawn

A118 Lymphoproliferative syndromes in major salivary glands M. Cisternas Bittencourt*, E. De la O Corrochano, G. Fernandez Rodriguez, F. Ramos Puerto, M. De Saa Alvarez, G. Pardo Romero, J. Herrero Herrero Department of Otorhinolaryngology, Head and Neck Surgery, Hospital San Pedro de Alcantara, Ca´ceres, Spain Introduction: Primary malignant lymphomas of the salivary glands are uncommon, comprising only 1.7% of all salivary neoplasms. Although the parotid gland is, by far, the most common site of origin, malignant lymphomas may also involve, in descending order of

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 frequency, the submandibular gland, minor salivary glands, and sublingual gland. Malignant lymphomas are often clinically unsuspected, manifesting as nonspecific masses indistinguishable from other more common epithelial tumors. Materials and methods: A retrospective review of the clinical records and anatomical pathology files from 2001 through 2008 in our Department, disclosed 96 patients who had undergone surgery of the salivary glands. Four cases (4/96) were malignant lymphomas. The features of the medical records of the four patients are discussed. Results: Diagnosis was established in all patients with anatomical pathology examination of the surgical specimen. All cases were classified as non-Hodgkin’s lymphoma: one Burkitt lymphoma, two follicle center cell lymphoma and a B-cell non-Hodgkin’s lymphoma. All patients were referred to the Hematology Department for further investigation, staging and treatment. Conclusions: A salivary gland tumor, although rare, may be the first manifestation of malignant lymphoma or it may represent a secondary focus of disease in a patient with a known history of malignant lymphoma. Chemotherapy and radiotherapy are the preferred therapeutic options.

A119 Lysyl oxidase expression is an independent marker of prognosis and a predictor of lymph node metastasis in oral and oropharyngeal squamous cell carcinoma A. Albinger-Hegyi1*, S. Sto¨ckli2, H. Moch3, S. Schmid4, M. Tinguely3, I. Hegyi5 1 Department of Oto-Rhino-Laryngology, Head and Neck Surgery, University Hospital; 2Clinic of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland; 3 Department Pathology, Institute of Surgical Pathology, University Hospital Zuerich, Zurich, Switzerland; 4Clinic Bethanien, Zurich, Switzerland; 5Department of Dermatology, Inselspital Bern, University Hospital, University of Bern, Bern, Switzerland Purpose: To identify the pattern of lysyl oxidase (LOX) expression in oral and oropharyngeal squamous cell carcinoma (OSCC), as well as in premalignant lesions leading eventually to OSCC. Analysis of the eligibility of LOX expression as a prognostic marker in patients with OSCC and as a predictor of lymph node disease. Experimental design: Using the whole human genome microarray (Agilent), we identified LOX as a differentially expressed gene in OSCC. Additional confirmation was performed by quantitative reverse transcription-polymerase chain reaction (QRT-PCR). Expression of LOX in normal mucosa, premalignant samples and OSCC was immunohistochemically analyzed on two tissue microarrays (465 tissue samples in total). Results: The results of normalized QRT-PCR confirmed the cDNA microarray result of increased expression of LOX mRNA in OSCC. Significantly higher expression of LOX was detected in high grade dysplastic mucosa as well as OSCC when compared to normal oral mucosa (P \ 0.0001). High LOX expression was correlated with lymph node metastases for the entire cohort (P \ 0.000), as well as in small primary tumours (T1/T2). High LOX expression was correlated with poor overall survival (P \ 0.004) and disease specific survival (P \ 0.038). In a multivariate analysis, high LOX expression was an independent prognostic factor, predicting unfavourable overall survival.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Conclusions: LOX expression is an independent prognostic biomarker and a predictor of lymph node metastasis in OSCC. Moreover, LOX overexpression may be an early phenomenon in the pathogenesis of OSCC and thus an attractive novel target for chemopreventive and therapeutic strategies.

A120 Malignant tumors of the parotid glands: the oncological and functional results with special regard to patients with facial nerve anastomosis M. Wierzbicka*, W. Szyfter, T. Kopeæ ENT Department, University of Medical Sciences, Poznan, Poland Aim: The aim of this study was to determine treatment modalities, complications and results in patients operated for parotid gland malignancies. Materials and methods: We retrospectively reviewed the medical records of 778 patients operated during the period from 1995 to 2005 for parotid gland tumors. In this number were 103 malignant staged as T1– 19, T2–53, T3–15, T4–16. The age ranged from 12 to 88, mean 57. The most common tumor were adenoid cystic carcinoma (30 cases), followed by mucoepidermoid and acinic cell carcinoma. Time of symptoms duration was from 1 to 120, mean 12 months. Diameter of tumor ranged from 1 to 9, mean 3 cm. Facial palsy at the time of presentation were observed in 28 patients, mostly in squamous cell cancers (6). Results: Treatment method depends on tumor stage and histological grade, standardized superficial (55) and total parotidectomy (48) were performed, in 3 cases combined with facial nerve resection followed by anastomosis. In 14 cases risk factors (infiltration of perineurium, lymphatics or blood vessels) were stated. Regional metastases were confirmed in 29. 48 were sent to adjuvant radiotherapy. 3- and 5-year overall survival rates were 62 and 55% respectively. Multivariant analysis showed, that parameters which significantly affected survival were elderly age, tumor advancement and risk factors stated in surgical specimen histological examination. Special emphasis was put to functional and oncological outcomes in patients with facial nerve resection and reconstruction by means of auricular major anastomosis.

A121 Management of sleep disorders, paradigm shift S. Al-Abdulwahed* Withdrawn

A122 MCL-1 expression: a new diagnostic marker to differentiate between benign and malignant tumors of the parotid gland? G. Heiduschka1, B. Erovic1, P. Kloimstein1, M. Brunner1*, A. Kaider2, D. Thurnher1 1 Klinik fu¨r Hals-, Nasen- und Ohrenheilkunde, Medizinische Universita¨t Wien, Vienna, Austria; 2Institut

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fu¨r klinische Statistik, Medizinische Universita¨t Wien, Vienna, Austria Background: Parotid gland tumors represent a rare entity among human malignancies. Their variety of classifications and the heterogeneous tissue architecture challenge the pathologists. The aim of the study was to assess whether mcl-1 protein could serve as a new diagnostic or prognostic marker in parotid gland tumors. Materials and methods: A tissue micro array containing archival material from 108 patients (50 f, 58 m, median age 61.7 years) was constructed. Tumor entities included adenocarcinoma (n = 17), adenoid cystic carcinoma (n = 12), acinic cell carcinoma (n = 6), mucoepidermoid carcinoma (n = 12) and squamous cell carcinoma (n = 28). Pleomorphic adenoma served as control (n = 31). mcl-1 protein was stained and the expression intensity was evaluated. Statistical analysis was carried out to compare expression of malignant tumors with the control group. Univariate and multiple Cox-regression models were performed to evaluate the unadjusted and tumor-type-adjusted effect of mcl-1 expression on survival. Results: Expression of mcl-1 protein was significantly higher in each group of malignant entities compared to pleomorphic adenomas (P \ 0.0178). In malignant tumors mcl-1 expression has no significant correlation with survival. Discussion: Our preliminary data show that expression of mcl-1 is not a prognostic factor for malignant tumors of the parotid gland. However, it can be used as an additional molecular tool to discriminate between benign and malignant tumors.

A123 Melanoma malignat at maxillary sinus and right orbit eight and a half years after removed primary uveal melanboma combine with hepatocellular carcinoma D. Markovski*, K. Dzambazov, D. Pazardzikliev, H. Zeliazkov UMBAL Malignant melanoma is a highly lethal melanocytic neoplasm. Its origin from turbinates or maxillary sinuses is extremely rare. These melanomas in the paranasal sinuses are most likely to evolve as regional metastases, although it is possible that they arise de novo or as related foci in accordance with the multicentric characteristics of uveal melanoma. Case report: Uveal melanoma diagnosed and removed by surgical resection (enucleating of the left eye) in January 1999 followed by 5 curses of chemotherapy and immunotherapy. At March 2007 in the control abdominal ehography was detect lesion of the liver 3.5 cm. hepatocellular carcinoma cured with radio frequent ablation. In June 2007 we diagnosed malignant melanoma at maxillary sinus, 8 and half year after the primary localization of melanoma. Histopathological result at the two melanomas was same type, epitheloid cellular malignant melanoma. S-100 /+/ Purpose: To report probably unique case within similar correlation. Methods: We removed the tumor, using modified Dieffenbach– Weber–Fergusson approach combined with Caldwell–Luke.

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A124 Minimally invasive video-assisted thyroidectomy (MIVAT): 2 years experience M. Bura*, H. Galic´, M. Zˇizˇic´-Mitrecˇic´, M. Rudesˇ, B. Bumber University Hospital Center We report our 2 years experience in the treatment of thyroid disease with minimally invasive video-assisted thyroidectomy (MIVAT) introduced by Miccoli. Methods: The procedure is carried out through an incision of 16– 22 mm and the thyroidectomy is performed by instruments specially designed for this method. Conditions were: thyroid nodule maximum in diameter of 30 mm, total thyroid volume under 30 ml, no signs associated thyroiditis, cytologic diagnosis of benign thyroid nodule or papillary microcarcinoma and without evidence of nodal disease on the neck. Results: We have treated (2006–2008) 53 patients with MIVAT. In this study 34 patients had lobectomy, 6 lobectomy with isthmectomy, 12 total thyroidectomy and one of them lobectomy with contralateral parathyroidectomy. Mean operative time for lobectomy was 62 min, range 41–110 min and for total thyroidectomy mean time was 106 min, ranged from 80 to 145 min. Duration of operations became shorter as we became more experienced. There was no postoperative bleeding. We had two transitient recurrent nerve palsy and none of the permanent recurrent nerve palsy. We had two permanent hypocalcemia. Conclusions: MIVAT is a safe technique with an indication in a minority of patients, candidates to thyroidectomy and is characterized by a better postoperative scar.

A125 Modified extended half-apron incision for planned neck dissections following organ preservation therapy for head and neck squamous cell carcinoma R. Simo*, J. Jeannon, A. Manganaris, G. Bruch Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK Introduction: Patients with locally advanced head and neck squamous cell carcinomas (HNSCC) are increasingly treated with chemo-radiation therapy (CRT) followed by staged planned neck dissection (PND). Radiotherapy (RT) or CRT produces an inflammatory reaction followed by fibrosis, having an adverse effect on the surgical morbidity. The aim of this study is to describe our experience on the use of a modified extended half-apron incision (MEHAI) for PND. Methods: Retrospective review of 28 patients treated with organ preservation therapy for locally advanced HNSCC that have undergone PND after CRT or RT, between September 2003 to date. Data on the type of surger, peri-operative and post-operative complications has been collected and analyzed. Results: Twenty-five patients have undergone CRT and 3 RT. Two patients underwent selective ND, 22 patients had a modified radical ND, 2 had a radical ND and 2 extended RND. The mean time between ending CRT or RT and undergoing surgery was 42 days. Fourteen patients underwent PND via a MEHAI. Surgical complications were seen in 15 (53%) patients, being seroma the most common one. No tissue breakdown was observed in patients who underwent MEHAI as opposed to other incisions.

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Conclusions: Planned ND following chemo-radiation treatment for carcinoma of the upper aerodigestive tract is increasingly used but remains controversial for patients with a complete clinical response. PND is associated with significant morbidity and potential tissue breakdown. The use of a MEHAI allows adequate access to all levels of the neck and minimizes the risk tissue breakdown.

A126 Murine model for intranasal inoculation E. Prades*, S. Rojas, G. Jose Maria, A. Isam, M. Joaquim, B. Manuel Department of Otorhinolaryngology, Hospital Clinic, Barcelona, Spain Introduction: Murine models of allergy, vaccination and rhinosinusitis have biodistribution models for intranasal inoculation that improve the retention of administrated substances in the upper respiratory tract (URT). We describe a model of biodistribution based on variables already studied as well as the partial injury of the nasosinusal mucosa. Materials and methods: Forty-six Balb/C mice were instilled Evan’s blue intranasally. After dissection of the tissue (upper and lower respiratory tract) the percentage of the recovered tracer was quantified by fluorimetry. For the statistical analysis multiple linear regressions (SPSS 15.0) were used. Results: The injury of the mucosa and the volume administered in the nasal cavity demonstrate a significant effect on the retention of the tracer along the URT. Previous surgery demonstrates an increase of the tracer of 18.4% (P \ 0.001) in the nasal cavity. Inversely, each lL of Evan’s blue administered over the dosage of 1.8 lL, there is a reduction of -2.1% (P \ 0.001) of retention in the nasal cavity. Deposition of Evan’s blue in the lower respiratory tract is minimal (\1%). Previous injury of the mucosa increases this retention independently suggesting an absence of recovery of the normal ciliary mechanism 1 week after the surgery. This effect can be used to maximize nasal retention of substances or to simulate a ciliary impairment in chronic rhinosinusitis models.

A127 Narrow band imaging (NBI) and high definition television (HDTV) in head and neck (HN) SCC after chemoradiotherapy (CHT-RT) C. Piazza*, D. Cocco, F. Del Bon, L. De Benedetto, P. Valotti, G. Peretti University of Brescia, Brescia, Italy NBI is a novel technique in which a filtered light enhances mucosal vasculature and better identifies neoangiogenetic patterns. NBI is implemented by combining it with HDTV. Our aim was to prospectively evaluate the diagnostic gain of NBI ± HDTV in HNSCCs previously treated by RT or CHT-RT. Between 2007 and 2008, we evaluated 64 patients treated by RT or CHT-RT for HNSCC. They were submitted to flexible WL and NBI videoendoscopy. Surgical candidates underwent intraoperative WL and NBI endoscopy with HDTV. Sensitivity, specificity, positive, negative predictive values, and accuracy were calculated. 12 out of 64 (19%) patients showed

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 adjunctive preoperative NBI videoendoscopic findings when compared to WL. All of them were confirmed by intraoperative HDTV NBI, while only 6 (50%) were evident during HDTV WL. 11 out of 12 (92%) lesions were confirmed as invasive or intraepithelial neoplasia. Sensitivity of flexible NBI, HDTV NBI, and HDTV WL was 100, 100, 54%. Specificity was 98, 98, 100%. Positive predictive value was 91, 91, 100%. Negative predictive value was 100, 100, 91%. Accuracy was 82, 82, 71%. NBI ± HDTV is useful in better defining tumor extension (upstaging of 2 tumors). NBI has also a role in the detection of early recurrences or persistences (8) and metachronous tumors (1). Overall, 11 out of 64 (17%) patients of this series had a diagnostic gain by the application of these techniques. By contrast, only 1 out of 64 (1.6%) turned out to be a false positive.

A128 Nasopharyngeal endoscopic resection (NER) in the management of selected malignancies: surgical technique and preliminary results A. Pistochini1, M. Bignami1, P. Battaglia,1, A. Bolzoni Villaret2, S. Mauri1, A. Bizzoni2, P. Nicolai2, P. Castelnuovo1 1 Department of Otorhinolaryngology, University of Insubria, Varese, Italy; 2Department of Otorhinolaryngology, University of Brescia, Brescia, Italy Introduction: This study evaluated the efficacy of endoscopic surgery in the management of selected, previously untreated or recurrent nasopharyngeal tumors (NPT). Three different type of nasopharyngeal endocopic resections (NER) are described in relation to local extension of the disease. Methods: From January 1997 to October 2008, 17 patients with previously untreated (5) or recurrent NPT (12) were treated with curative intent by pure endoscopic resection in two referral University Hospitals. The extent of surgical resection was classified as follows: type 1 NER: resection limited to the postero-superior NP wall reaching the bony floor of the sphenoid sinus; type 2 NER: resection superiorly extended to the sphenoid sinus; type 3 NER: resection with lateral extension including the cartilaginous portion of the Eustachian tube and parapharyngeal space. Results: Type 1 NER was performed in 4 cases, type 2 in 6, and type 3 in 7. No intra or postoperative complications were observed. The lesions were staged as follows: stage I, 10 (63%); stage II, 2 (12%); stage III, 3 (13%) and stage IV, 2 (12%). The follow-up time ranged from 1 to 129 months (mean 33). At the time of last follow up, 12 (71%) patients were free of disease, 3 (17%) alive with disease, 2 (12%) dead of disease. Discussion: These preliminary results show that NER is a feasible surgical technique in the treatment of selected, previously untreated or recurrent NPTs which can be modulated in relation to tumor extension.

A129 Necrotizing fascitis of the head and neck: various clinical presentations and outcomes M. M. Shaariyah1, M. B. Marina1, M. Y. Mohd Razif1, S. H. A. Primuharsa Putra2 1 Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, National University of

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Malaysia, Kuala Lumpur, Malaysia; 2Ear, Nose, ThroatHead and Neck Consultant Clinic, Seremban Specialist Hospital, Seremban, Malaysia Introduction: Necrotizing fasciitis of the head and neck is a rare, rapidly progressive infection involving the skin, subcutaneous tissue and fascia. It commonly occurs in diabetic and immunocompromised patients. The infectious agent in this potentially fatal disease is usually due to Group A Streptococci bacteria. Case report/result: We report 3 cases of necrotizing fasciitis, each differ in their presentation and outcome. The first case involves a patient who presented with a progressively enlarging anterior neck swelling that was later complicated with dysphagia, vomiting, dehydration and reduce conscious level. Our second case complained of left neck swelling with left otorrhea. The third case involved a patient with left buccal ulcer complicated by left facial pain and swelling which progressively extended down to the neck. All of them had underlying diabetes mellitus which was poorly controlled in 2 of them. All of them underwent fasciotomy with wound debridement and additional cortical mastoidectomy with myringotomy and grommet insertion for second case. Two of these patients recovered well, however the third case unfortunately succumbed to his disease due to progressive spreading of infection into the larynx and complicated by septicemia with multiorgan dysfunction despite active management. Conclusion: This paper stresses on the importance of eradicating the source of infection, frequent meticulous dressing, control of blood sugar to obtain a better outcome in managing necrotizing fasciitis of the head and neck. Involvement of the airway indicate poor prognosis.

A130 Necrotizing sialometaplasia of nasopharynx with parapharyngeal extension S. Kumar1*, A. Qayyum2, N. Bhat3 1 Peterborough and Stamford Hospital NHS Trust, Peterborough, UK Objectives: To report a rare tumour at a rare site and a brief review of literature. Methods: Patient was admitted as an emergency with sore throat, weight loss, fever and trismus for 5 weeks. Clinical examination and MRI scan of the neck were suggestive of a malignant pathology in the nasopharynx, right parapharyngeal space and the soft palate. First biopsy taken from nasopharynx and soft palate did not reveal any malignancy but showed active chronic inflammation in soft palate but repeat biopsy and review of the slides at a university hospital revealed it to be necrotizing sialometaplasia. Results: Necrotizing sialometaplasia is known to affect minor salivary glands in the palate but its occurrence in nasopharynx and involvement of parapharyngeal space and hypopharynx has never been reported in English literature. This lesion resolved spontaneously on conservative treatment over a period of 6 months after histological confirmation. Conclusions: This condition poses a diagnostic challenge as rapid growth and clinical and radiological picture mimics a malignancy but in reality is a self limiting condition. Failure to recognize it can result in unnecessary investigations and unwarranted extensive surgery.

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A131 New technologies in thyroid surgery: an institutional experience D. Prgomet* Department of Otorhinolaryngology, Head and Neck Surgery, Zagreb, Croatia Objectives: In the last decade thyroid surgery has been highly driven by emerging technologies that enabled reduction of operative time, better hemostasis, minimally invasive approaches and cranial nerve monitoring. We present our institutional experience with the harmonic scalpel and intraoperative neuromonitoring of the recurrent nerve in thyroid surgery. Patients and methods: Over the 4-year period we performed more than 500 thyroidectomies using two different harmonic scalpels (the Harmonic ACETM and the Harmonic FOCUSTM). We evaluated operative time, intraoperative blood loss and complication rate in comparison with conventional surgery and hemostasis with electrocoagulation and ligatures. Intraoperative electromyographic monitoring of the recurrent laryngeal nerve with endotracheal electrodes was employed in 40 standard and 17 difficult (reoperation, large goiters, invasive carcinoma and pediatric patients) thyroid procedures, and compared with the value of intraoperative visual nerve identification, and in regard to different surgical techniques. Results: The use of both Harmonic ACETM and Harmonic FOCUSTM scalpel reduced the time of thyroid surgery by 25% as compared with conventional techniques. The use of both devices enabled better hemostasis, better cosmetic result and significantly less intraoperative drainage placement. Postoperative complications were comparable between groups. Neuromonitoring is effective in providing identification and function of laryngeal nerves, especially in difficult procedures. While neuromonitoring enabled surgeons to feel more comfortable and shortened operative time in difficult procedures, we did not find significantly different palsy rates in comparison with visual nerve identification. Conclusions: Novel technologies in thyroid surgery are feasible, safe, and easy to perform, offering the plain benefit.

A132 New way of management of ENT manifestation of gastroesophageal reflux disease (GERD) V. Kokorina* ENT Department, Far Eastern State Medical University, Vladivostok, Russia Objectives: The present study is aimed at assessing the clinical efficiency of a combination of transcranial electrostimulation with proton pump inhibitors in treatment of ENT diseases associated with gastroesophageal reflux. Laryngopharyngeal reflux (LPR) has been increasingly recognized as cause of chronic laryngeal symptoms which caused by dysfunction of the upper esophageal sphincter. Transcranial electrostimulation (TES) of endorphinrrgic structures of the human brain facilitates help to normalized neuroregulation of upper esophageal sphincter. Design: 256 patients with laryngopharyngeal reflux was treated. Patients were divided onto 2 groups: first—monotherapy LPR with proton pump inhibitors for 3 months combine with placebo stimulation; second—therapy of LPR with combination of TES with proton

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 pump inhibitors for 3 months. The frequency and severity of reflux and laryngeal symptoms were scored and laryngitis graded by laryngoscopy. All patients underwent esophagogastroduodenoscopy and 24-h ambulatory pH monitoring before and 3 and 6 months after treatment. Results: TES of the endorphinrrgic structures repairing the incompetent upper esophageal sphincter and significantly reduce both acid and nonacid refluxate. TES has proved to be effective in controlling reflux by inhibiting transient, inappropriate upper esophageal sphincter relaxation, increasing upper esophageal sphincter pressure. A combination of treatment: the proportion of patients with marked improvement in laryngeal symptoms were significantly higher in the group with combination of PPI with transcranial electrostimulation. Summary: Non invasive transcranial electrostimulation (TES) for the treatment of laryngopharyngeal reflux should be considered as the main part of the combine treatment for the LPR-associated vENT diseases.

A133 Nose and ear foreign body in children F. Manole* University of Oradea, Oradea, Romania Infants and young children frequently insert foreign bodies into the nose. The cause of any unilateral offensive nasal discharge in a young child is a nasal foreign body until proved otherwise. The removal of foreign bodies in children is very common in the otolaryngologist’s daily routine. We present a prospective series of 65 cases of ear and nose foreign bodies removed from children aged 0–12 years old in period 2007–2008 in Pediatric Hospital. From this, 35 females (53.8%) and 30 males (46.1%); 42 children (64.6%) aged from 1 to 2 years, 23 (35.3%) from 3 to 5 years. There were 28 cases (43%) of ear foreign bodies, in which a bean was the most common (24.73%), and 37 cases (50.27%) of nose foreign bodies, in which sponge fragments peanuts, berries, paper, and foam rubber was predominated (36.17%). There was one case of button batteries (hearing aid-type batteries) who produce an extremely severe chemical reaction within the nasal cavity. In all cases, the removal was performed within the first 24 h after the foreign body insertion, and 46 of the patients had previous attempts to remove it. Ten cases with complications (external ear canal lacerations, tympanic membrane perforation) were observed in patients in whom these previous attempts had been made, but there were no sequelae. We conclude that younger children are more prone to insert foreign bodies. Complications may occur as a result of attempts to remove the foreign body without the help of specialised personnel or proper conditions.

A134 Oesophageal foreign bodies: results of a retrospective series of 517 cases G. Pudar1*, L. Vlaski2 1 General Hospital, Novi Sad, Serbia; 2ENT Clinic, Medical Faculty, University of Novi Sad, Novi Sad, Serbia Introduction: A retrospective study of Rigid Esophagoscopy, with the suspect of foreign body, was performed during the period of 1988– 2007. Results: From the total of 517 esophagoscopies, 203 (39.26%) foreign bodies have been found, with the average of 7.8 annually per

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 100,000 inhabitants. Patients age rate was from 1 to 91 years (X = 48.98). Considering gender, there were 95 male patients (46.79%), and 108 female patients (53.21%). The most of found foreign bodies was at patients within age interval of 60–69, (43/22,15%). According to kind of foreign bodies the most frequent were animal origin bones (86/42.36%), afterwards, there come meat bolus (67/33%), metal coins (23/11.33%), vegetative origin bodies (14/6.89%), metal, plastic or wooden objects (8/3.94%), dental prosthesis or parts of those prosthesis (5/2.46%). In regard to the level at which foreign body was found [described in 157 cases (77.30%)], at the pharyngoesophageal junction, there were 94 (59.87%) cases, middle constriction of oesophagus 58 (36.94%) cases, and in the area of diaphragmatic constriction and cardia, 5 (3.18%) cases. The efficiency of removing foreign bodies by rigid esophagoscopy was 99.01% (201/203). In 2 cases (0.99%), due to impaction of foreign body, patient were referred to higher tertiary unit institution. Conclusion: Foreign bodies represent constant casuistry in Zrenjanin Municipality, dominantly connected to work of otolaryngologist during attendance. Rigid esophagoscopy is safe and efficient diagnostic and therapeutic method.

A135 Operations on the parotid gland in children V. Jo´sa*, M. Mo´nos, M. Becske Department of Oto-Rhino-Laryngology and Head and Neck Surgery, Ferenc Flo´r Pest Regional Hospital, Budapest, Hungary Parotid tumours are rare in children. There are no strict guidelines in the treatment as the number of patients is small. Our department is a centre for parotid gland diseases in Hungary. Charts concerning operations performed in the parotid region in children were reviewed retrospectively. The age of patients, localization, histology, type of surgery, postoperative facial nerve function and recurrence rate were analysed. We identified 76 patients operated on between 1986 and 2005. The average age was 10.8 years. There was only a slight difference in the localisation of the lesions (45.45% preauricular, 54.5% retromandibular), whereas the majority of them were in the superficial lobe. 43.4% were benign lesions such as cysts, lymphadenitis, fistulae or chronic inflammation. 56.6% of the patients were operated because of tumours: 31 benign tumours were found such as pleomorphic adenoma, haemangioma, lymphangioma and pilomatrixoma whereas 12 of the cases were malignant such as mucoepidermoid carcinoma, acinic cell tumour. In 3 cases enucleation, in 51 cases superficial parotidectomy, while in 21 cases total parotidectomy was performed. In 6 cases recurrence occurred and revision surgery was required. After surgery temporary facial nerve weakness was observed in 16 cases. It is important that operations on the parotid gland in the pediatric populations should be performed in centres to ensure optimal treatment for children and to avoid severe complications such as facial nerve paralysis. An international guideline is still required. We hope that our results can contribute to establish it.

A136 Oropharyngeal cancer: habitual and professional factors involved in evolution and prognosis I. Comsa1*, L. Hangan2 1 ENT Clinic of School of Medicine, Ovidius University of Constanta, Constanta, Romania; 2Medical Informatics and

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Biostistics Department, School of Medicine, Ovidius University of Constanta, Constanta, Romania The prevalence of oropharyngeal cancer shows a disturbing increase of cases with an aggressive evolution and a poor prognosis. The authors based on clinical experience and active tracking over a period of over 10 years of patients with oropharyngeal cancer, explores the relationship between different factors (environmental, habitual and professional) and the evolution and prognosis of affection. The retrospective study based upon 126 cases is completed with a prospective study along years. The medical education stays behind the success of early diagnosis and medical survey of oropharyngeal cancer. We suggest the adding of specific screening for oropharyngeal cancer in periodical medical check-ups. Collaboration between family doctor and ENT specialist is very important.

A137 Ossified thyroglossal duct cyst: a rare entity E. De La O Corrochano*, M. Cisternas Bittencourt, G. Fernandez Rodriguez, M. Castro Canelada, M. De Saa Alvarez, M. Lavilla Martin de Valmaseda, J. Marcos Calle Department of Otorhinolaryngology, Head and Neck Surgery, Hospital San Pedro de Alcantara, Ca´ceres, Spain Introduction: A thyroglossal duct cyst is a rare but occasional cause of a benign midline neck mass, its ossification is extremely rare and may lead to difficulties in the diagnosis of an osseous neck mass. Methods: The medical record of a 46-year-old woman, remitted by the endocrinologist for assessment of an upper midline neck tumor is discussed. Results: The patient had a long-term history of a painless upper midline neck tumor, with no dyspnea or hoarseness. The radiological images of the CT revealed a heterogeneous osseous and cystic tumor in relation with the hyoid bone. The patient underwent surgery with the resection of the tumor including the body and minor horns of the hyoid bone. The pathologic diagnosis was ossified thyroglossal duct cyst. Conclusions: Ossification of a long-term thyroglossal duct cyst is rare, but may occur. Radiological studies are needed to evaluate size, location, signs of malignancy and surgery planning of the mass. Surgical treatment is the standard therapy.

A138 Osteochondroma of the mandibular condyle U. Bolinaga*, P. Martinez Seijas, N. Perez, R. Lobato, J. Arruti Hospital Donostia San Sebastian, Spain Introduction: Osteochondroma is a benign tumour in the axial skeleton. Most frequent benign tumours of the temporomaxillar joint are osteoma and ostechondroma. The normal clinic history is: progressive facial asymmetry, progressive malocclusion and alterated joint function. Clinical case: 34-year-old, female patient, that presented progressive malocclusion and facial asymmetry. Clinical examination showed dissoclusion and the dental midline desviated to the right. In

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1076 the orthopantomogram and CT scan revealed in the left TMJ an exostosis in the medial and anterior region of the condileal head. The clinical diagnosis was a left TMJ osteochondroma. The surgical treatment carried out was a left condilectomy with remodeling of the condileal rest and disk anchored reposition to the condileal head. Discussion: The most frequent benign tumours of the temporomaxillar joint (TMJ) are osteoma and ostechondroma. The clinical charecteristics are: progressive asymmetry and progressive malocclusion. The panoramic X-ray shows an alterated anterior condileal contour. Surgery is the treatment of choice and operative technique used is condilectomy and disk anchor. Conclusions: •

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Patient with progressive facial asymmetry and progressive lateral open bite with dental midline deviation, should make us suspect hiperplasia, osteoma or osteochondroma of TMJ. CT scan is useful in differential diagnosis with osteoma. Bone scintigraphy demonstrates tumour activity and shows if other regions are affected. Orthodontics is a good treatment in order to achieve the best normal occlusion. Treatment is surgical (condilectomy and in some cases CSSO, BSSO, asymmetric Le Fort I osteotomy and remodeling of basal mandibular body bone).

A139 Osteonecrosis: a severe side effect of bisphosphonate therapy G. Fu¨lo¨p* Department of Oral and Maxillofacial Surgery, Kaposi Mo´r County Hospital, Kaposvar, Hungary Objectives: Osteonecrosis is a well known side effect of radiotherapy of cancers in the head and neck region. However mandibular and maxillar osteonecrosis can occur as a sever side effect of bisphosphonate therapy as well. In our presentation we emphasize the role of prevention. Management of osteonecrosis means a great therapeutic challenge. Methods: Bisphosphonates inhibit the osteoclast-mediated bone resorption. The treatment is effective in reducing the number of bone metastases and skeletal morbidity. Using bisphosphonates the quality of life is significantly improved. As a result bisphosphonates have taken part in the routine management of cancers causing bone metastases like cancer of the breast or prostate, etc. In our presentation beside discussing the pathomechanism of osteonecrosis caused by bisphosphonates we demonstrate our experience achieved by managing 32 patients between 01.09.2005 and 30.11.2008. Results: In the presented cases the neglected dental status and inflammation or extraction of teeth were the immediate reasons of osteonecrosis that can set in spontaneously as well. The clinical features are variable including denudated bone surface and purulent fistular discharge. Clinical alterations, orthopan tomography and CT test were used to prove the diagnosis of osteonecrosis. After interrupting bisphosphonate therapy we inducted parenteral antibiotics. In some cases surgical treatment was performed as well beside conservative therapy. Conclusions: According to our experience interdisciplinar therapeutic approach and full oral sanation before inducting bisphosphonate therapy can lead to significant regression of the incidence of osteonecrosis.

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A140 Our experience concerning some of the embryonic vestiges of the head and neck M. Mutu*, S. Codreanu, T. Ataman Institute of Phono-Audiology and ENT Functional Surgery ‘Prof. Dr. D. Hociota’, Bucharest, Romania The head and neck are one of the most complicated structures that the embryo forms, with specialized intermediate structures (the pharyngeal arches) and contributions from all 3 embryonic layers (ectoderm, mesoderm, endoderm), and significantly, a major contribution from the neural crest. It is therefore not uncommon for this body region to have many associated abnormalities. We present a retrospective study of admissions with embryological abnormalities at Institute of PhonoAudiology and ENT Functional Surgery ‘Prof Dr. D. Hociota’ between 2006 and 2008. Our review included 81 patients, 37 females and 44 males. The main pathologies encountered were thyroglossal duct cyst, branchial cysts and coloboma auris. More then half (49 patients) of the cases were thyroglossal duct cyst. Many of these patients were asymptomatic for a long period, the average age of the onset of symptoms being 30.07 years. When symptoms occurred the only definitive method of treatment was surgical excision. The main method of treatment was surgery. Head and neck embryological abnormalities present a challenging diagnosis and management. A correct preoperative diagnosis may require additional methods of investigation, such as ultrasonography, computed tomography or magnetic nuclear resonance imaging. Complete removal of the abnormal structure, without complications, depends upon a good understanding of regional embriogenesis, a knowledge of circumstances surrounding discovery, an awareness of the different anatomical presentations.

A141 Our experience in endoscopic management of relapsed juvenile nasal angiofibroma M. Nersesyan1*, D. Kapitanov, A. Lopatin2, V. Cherekaev, D. Golbin, A. Lubnin, S. Yakovlev, P. Dorohov, S. Arustamyan, E. Buharin 1 The Burdenko Neurosurgery Institute, Russian Academy of Medical Sciences, Moscow, Russia; 2Moscow Medical Academy, Moscow, Russia Many reports recently have advocated the feasibility of endoscopic resection of juvenile nasal angiofibroma. We proposed to share our experience with 18 cases of relapsed juvenile nasal angiofibroma operated on endoscopically in our Institute and discuss clinical symptoms, methods of diagnostics, indications for the endoscopic approach to relapsed tumors, preoperative conditions, difficulties of surgery, possible complications and surgical outcomes. of 56 patients with juvenile nasal angiofibroma have operated on in our Institute since 2004 year, 32 patients were operated on by neurosurgical approach, 24—endoscopically. 43 patients who previously had been operated on 1–3 times at other clinics 18 were operated on exclusively endoscopically. 9 of these patients also had previous radiation therapy. All the patients were males, of the age 10–22 years old (mean 16 years old). The follow-up period ranged from 6 to 52 months (mean 12 months). Endoscopic resection of juvenile nasal

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 angiofibroma can be considering as a method of choice even in patients with relapsed tumors as it is an effective, less traumatic method of its treatment with a good surgical outcomes. However, preoperative tumor embolization, intraoperative blood safe methods, such as isovolemic hemodilution, Cell-saver autoblood reinfusion need to be used as these type of surgery mostly accompany with higher risk of bleeding.

A142 Our therapeutical attitude concerning the treatment of thyroid cancer with laringo-tracheal invasion, oesofagial invasion or exteriorization H. Mocanu1*, A. Marcu1, A. Agache2, C. Stan2, L. Luhan2, D. Manu1 1 Titu Maiorescu University, Bucharest, Romania; 2 Ilfov Clinical Emergency Hospital, Bucharest, Romania By enlarged thyroidectomy we mean the surgical intervention which consists in total thyroidectomy and resection of neighbouring invaded structures (cervical viscerai, muscles, blood vessels). Between 2000 and 2007 in our clinic were operated 6 cases of thyroid cancer with tracheal invasion, 6 cases with laringian invasion and 4 cases with invasion of the faringo-oesofagial wall. In case of tracheal invasion, the histopathological diagnosis of the malignant nature of the invasion is mandatory and it justifies a circular tracheal resection followed by reconstruction. No oesophageal resections were made because we considered this type of tumoral invasion as beyond reasonable surgical limits of the thyroid cancer. Our goal is to present our surgical attitude for each type of tumoral invasion, our results and also to prove that for a specialized surgeon, trained for interventions on the superior respiratory and digestive structures, this type of enlarged resections and reparing the defects poses no technical problems.

A143 Papillary endothelial hyperplasia within external jugular vein: a rare diagnosis of lateral neck mass N. Tangjaturonrasme* Department of Otolaryngology, Chulalongkorn University, Bangkok, Thailand Papillary endothelial hyperplasia (PEH) is a rare differential diagnosis of a lateral neck mass with 33 percent incidence that occur in the head and neck region. A case of Thai male 65-year-old presented with a lateral cord-like neck mass for one week. Imaging studies (USG and CT scan) revealed thrombosis of the external jugular vein with initially unknown etiology. The thrombosed vein was uneventfully excised with a final histopathology report as PEH. This case report described the finding of PEH within the external jugular vein that presented with lateral neck mass, not previously mentioned before in the literature search. Differential diagnosis must be rule out from angiosarcoma due to mimicking pathological character. Complete surgical excision is the treatment of choice. Keywords: Papillary endothelial hyperplasia, Masson’s tumor, External jugular vein, Angiosarcoma, Lateral neck mass

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A144 Paragangliomas of the neck W. Szyfter, T. Kopec*, L. Bartkowiak Department of Otolaryngology, Poznan University of Medical Sciences, Poznan, Poland Paragangliomas according to their site of origin and location can be divided into four groups: glomus caroticum, glomus jugulare, glomus vagale and glomus tympanicum. The first three types show the symptoms of the neck tumor. Lesions are highly vascularized and exhibit the ability of neurosecretion. The removal of the tumour may be the chosen treatment, yet not in every case it is advisable. Preoprative embolization of vessels supplying blood to the tumor significantly increases the comfort of the operating surgeon, makes the operation easier and reduces the risk connected with the loss of blood at the operation. At the Department of Otolaryngology and Oncology of the Medical University in Poznan, there have been 22 patients with the diagnosed paragangliomas of the neck treated between 2000 and 2008, 15 of them with glomus caroticum, 4 with glomus vagale, 2 with glomus jugulare and 1 patient had multiple tumours diagnosed. In the case of 16 patients, preoperative embolization of blood supplying vessels was performed 4– 10 days before the operation. One patient was diagnosed with bilateral glomus caroticum. Chemodectoma malignum was diagnosed in histopathological examination of 1 patient with glomus caroticum. In case of 1 patient with glomus jugulare, the lesion extended to the cranial basis and required partial exposure of the sigmoid sinus. One patient, diagnosed with multiple tumors (bilateral glomus caroticum, glomus jugulare and vagale) was not operated on. The authors focus on the course of treatment and its results in the analysed group of the patients.

A145 Parametric survival analysis for oral cancer compared to the Cox regression H. Ko¨hler1, L. Kowalski2 1 State University of Campinas, Campinas, Brazil; 2 Hospital A C Camargo, Sao Paulo, Brazil Introduction: To expose the differences in survival analysis from a when parametric survival model is compared to Cox model. Patients and methods: 709 consecutive patients treated at a single institution were analyzed. Variables regarding demographic, clinical, and pathological and treatment were analyzed at both models. Results: Using the Cox regression technique, the following factors were identified at univariate analysis: gender (P \ 0.001), complain history time (P = 0.007), tobacco use (P = 0.004), alcohol use (P \ 0.001), distance to midline (P = 0.001), diameter (P \ 0.001), mobility of cervical nodes (P = 0.003), T stage (P B 0.001), N stage (P \ 0.001), concurrent neck dissection (P \ 0.001), continuity of neck dissection specimen (P \ 0.001), ASA classification (P = 0.006), post-operative radiotherapy (P = 0.009), time for radiotherapy (P = 0.019), skin invasion (P \ 0.001), bone invasion (P = 0.019), lymphatic embolization (P \ 0.001), neural infiltration (P \ 0.001), compromised surgical margins (P \ 0.001) and tumor thickness (P \ 0.001). There was agreement with the parametric model in: gender (P \ 0.001), history time (P \ 0.001), tobacco consumption (P = 0.003), alcohol use (P \ 0.001), distance to median line (P = 0.006), diameter (P \ 0.001), nodes’ mobility (P = 0.006), T stage (p \ 0.001), N stage (p \ 0.001), concurrent neck dissection (p \ 0.001), continuity of neck dissection (P = 0.005), ASA

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1078 classification (P = 0.007), post-operative radiotherapy (P = 0.027), skin invasion (P = 0.005), lymphatic embolization (P \ 0.001), neural infiltration (P \ 0.001), surgical margins (P = 0.003) and tumor thickness (p \ 0.001). The multivariate model identified tumor diameter, time for radiotherapy, skin invasion, lymphatic embolization and N stage as significant in Cox regression and ASA, T stage, N stage and lymphatic embolization in the parametric model. Conclusion: Parametric models are considered more accurate and precise than the Cox regression and, in this series, identified different prognostic factors.

A146 Parotid duct repair with suturing and anastomosis using tissue adhesive, evaluated by sialography: an experimental study in the dog R. Gheisari1*, M. Ghoreishian2, A. Roozbehi3 1 Department of Oral and Maxillofacial Surgery, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran; 2Department of Oral and Maxillofacial Surgery, Torabinejad Dental Research Center, Isfahan University of Medical Sciences, Isfahan, Iran; 3Department of Anatomy, Yasuj University of Medical Sciences, Yasuj, Iran Purpose: The most common method of parotid duct anastomosis is suturing. Besides the postoperative complications in suturing (i.e. anastomosis leakage, fistula formation and infection of maxillofacial spaces), the surgical duration and suturing difficulties arise as major problems. The efficacy of fibrin glue in parotid duct anastomosis was evaluated, compared with suturing in 15 dogs. Materials and methods: Fifteen dogs were studied in this experimental trial. Intravenous Cephalothin (1 g) and intramuscular Dexamethasone (8 mg) were administered preoperatively for all cases but no drug was administered postoperatively. Extra-oral transverse incisions were made in buccal regions bilaterally to expose parotid ducts and transection was performed in similar areas (right and left). Then, the right transected duct was repaired with 7-0 nylon sutures and then left anastomosis was performed, using fibrin glue. Ten days after the operation, clinical evaluations and sialography were used to evaluate the quality of the anastomosis repair, ductal leakage and fistula. Results: The ductal fistula on the right was found in two cases and three cases to have ductal fistula in the left parotid duct. Aspiration was positive on the right side in two cases (vs. 5 positive aspirations) detected in left parotid ducts. Also, right ductal leakage was seen in four cases, using sialography (vs. 7 left ductal leakage). Conclusion: This study suggested that the efficacies of fibrin glue and suturing in parotid duct anastomosis were similar, but use of fibrin glue had a number of advantages including shortening of the surgical time and possibility of stent removal intraoperatively.

A147 Parotidectomy: 10 years Grampian experience M. Shakeel1*, A. Al-Adhami2, A. Canna2, A. Trinidade1, K. Ah-See1 1 Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK; 2School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Introduction: Parotidectomy is an established procedure for benign and malignant parotid gland pathologies. Objective: To evaluate the local practice at our institution, a tertiary referral centre in the Northeast of Scotland. Ethics: Approved by institutional Clinical Effectiveness department. Study design: Retrospective chart review. Method: Data were collected for all patients who underwent parotidectomy between 1996 and 2007. Demographics, clinical presentation and findings, investigations, type of surgery and postoperative complications were recorded. SPSS v16 was used for data storage and analysis. Results: There was equal gender distribution. The mean age was 53 years (4–84 years). Out of 204 patients, 68% underwent complete superficial (CSP), 30% had partial superficial (PSP) and 3 patients had total parotidectomy (TP). Preoperatively, 65% underwent MRI, 86% had a FNAC. There was a high prevalence of benign tumours (pleomorphic adenoma = 51%, Warthin’s tumour = 23%) and only 16 patients had a malignant tumour. Non-neoplastic conditions included sialadenitis, salivary gland cysts and sarcoidosis. The average time from presentation to operation was 9.9 months. A facial nerve monitor was used in 25% of patients. There was no incidence of permanent facial nerve paralysis but 26% experienced transient facial weakness post-operatively. Earlobe numbness or documented sacrifice of the greater auricular nerve was noted in half of patients. Gustatory sweating along with other wound complications were experienced by a small number of patients. Conclusion: Benign tumour is the most common parotid gland pathology requiring superficial parotidectomy. Our post-operative complications rate is comparable to the published literature.

A148 Patulous eustachian tube in bariatric surgery patients C. Aedo*, D. Mun˜oz, J. Gormaz, C. Der Hospital Clı´nico de la Universidad de Chile, Santiago, Chile Introduction: Patulous eustachian tube (PET) is associated with pregnancy, mucosal atrophy, muscular dysfunction and rapid weight loss. Rapid and significant weight loss in patients undergoing bariatric surgery may be risk factors for developing PET. Aim: To determine the prevalence of PET in patients undergoing bariatric surgery. Materials and methods: Prospective study design. We identified 88 patients who underwent bariatric surgery at the Hospital Clı´nico de la Universidad de Chile between 1999 and 2006. Seventy nine patients were analyzed by a survey and physical examination. Two groups were formed. The first was comprised of individuals who had PET and the second group had not. The intensity and duration of weight loss was compared between the two groups. We analyzed variables such as age, sex, clinical presentation of PET, initial and final BMI. Fischer0 s test was applied. Results: The average age was 59 years, of which 77.3% were women. We noted symptoms of PET in 20.25% (81.3% women). Autophony was present in 43.7%. Patients without PET experienced weight loss at an average of 42.14 kg during 17.8 months, while patients with PET experienced weight loss at an average of 42.9 kg during 15.2 months. The weight loss speed difference was statistically significant (P \ 0.05). Conclusion: Our series shows a significant prevalence of PET in patients who underwent bariatric surgery being found in correlation with rapid weight loss rather than weight loss of higher magnitude.

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A149 Pediatric facial nerve paralysis surgicaly treated in ENT Clinic, Clinical center of Vojvodina, Novi Sad evaluated between 1999 and 2008 L. Vlaski*, D. Dankuc, S. Lemajic-Komazec, Z. Komazec, V. Kljajic ENT Clinic Novi Sad, Clinical Center of Voivodina, Vojvodina, Serbia Objective: To characterize the causes, diagnostical procedures and surgical treatment of facial nerve paralysis (FNP) in children hospitalized in ENT Clinic Clinical center of Vojvodina Novi Sad, Serbia. The most common etiology of FNP in children is: infection, congenital, trauma, jatrogenic. Middle ear tumors are rare in children. Rhabdomyosarcoma is most common soft-tissue malignancy of the head and neck seen in childhood. Approximately 77% of all rhabdomyosarcomas occur in patients younger than 12 years of age and 43.5% occur in those younger than 5 years. The involvement of the middle ear and mastoid accounts for about 8–10% of head and neck rhabdomyosarcomas. Method: Retrospective study in the tertiary care ENT Clinic. Five patients identified with FNP evaluated between 1999 and 2008. A review of the medical records including sex, age, laterality, etiology, diagnostical procedures, surgical treatment, duration and degree of recovery. Results: Five cases of FNP. Causes of FNP are: mastoiditis (3/5), chronic secretory otitis media (1/5) and neoplastic (1/5). Diagnostical procedures included: history details, ENT examination (otomicroscopy), functional investigations, CT of temporal bones. Surgical treatment—cortical mastoidectomy and myringotomy with ventilation tube insertion (4/5). In the neoplastic case (1/5) intraoperatively we found unusual polypodal masses filling the antromastoidal tract, tympanic cavity and intraopertive decision was radical tympanomastoidectomy. The histopathologyc features of the biopsy specimen— embrional rhabdomyosarcoma. Conclusion: Careful examination of the ear is recommended and essential in children with signs of peripheral facial nerve laralysis. Keywords: Facial nerve paralysis, Pediatric, Rhabdomyosarcoma, Surgical treatment.

A150 Peritonsillar abscess associated with systematic diseases I. Bardanis* ENT Department, General Hospital of Ikaria, Ikaria, Greece Introduction: The relationship between infectious mononucleosis (IM) and peritonsillar abscess (PA) has already been documented in literature. The proportion of PA in patients with IM has been reported up to 23.4%. Objective: To present cases of PA in the course of systematic diseases referred to the ENT Department of our hospital. Materials and methods: In every case of PA the titers of IgM and IgG antibodies for Toxoplasma gondii and Cytomegalovirus, as well as Monospot test for heterophile antibodies have been checked. Results: Thirty-two cases of PA have been checked. In 2 cases Monospot test was positive and in 1 case the titer of IgM antibodies for Toxoplasma gondii was elevated. Conclusion: In this group of patients 9.38% of cases of PA has developed in course of a systematic disease. According to this, we

1079 would suggest the above mentioned laboratory check in every case of PA.

A151 Plasmacytoid dendritic cell subpopulations in tumor immunity: do we have to learn to think differently? A. Thiel, R. Pries, B. Wollenberg* Department of Otorhinolaryngology, University of Lu¨beck, Lu¨beck, Germany Plasmacytoid dendritic cells (PDCs) infiltrating solid tumor tissues and draining lymph nodes of head and neck squamous cell carcinoma (HNSCC) show an impaired immune response. Besides attenuated secretion of IFN-alpha and disturbed maturation, little is known about HNSCC induced functional alterations in PDCs. We isolated PDCs from human peripheral blood by ‘magnetic bead separation’ and stimulated them with tumor cells or supernatants. Cell surface characteristics were analysed by flow cytometry, cytokine secretion was examined by performing Bioplex assays. Fluorescence staining, immunohistology and tumor single cell suspensions were used to analyse PDCs in vivo. Migration assays were performed to evaluate tumor mobilisation towards cytokine stimuli. In our work we newly defined several minor PDC subpopulations which phenotypically resemble different cell lineages. We detected phenotypical and functional alterations in these subpopulations subsequently to incubation with HNSCC cell lines and furthermore demonstrated their existence in solid tumor and draining lymph nodes of tumor patients. Based on our results we are convinced that we have to start turning our attention towards minor subpopulations in tumor immunity, as HNSCC seems to be actively modifying subpopulations to it0 s benefit whilst functionally paralysing the majority of the PDC.

A152 Platysma musculofascial flap in reconstruction following partial vertical laryngeal resections M. Jurlina1*, Z. Matulic2, D. Prgomet1, R. Prstacic1 1 ENT Department, Clinical Hospital Center Zagreb, Kisˇpatic´eva 12, Zagreb, Croatia Investing layer of deep cervical fascia represents attractive reconstructive material after partial vertical laryngeal resections due to its low metabolic activity and consequent resistance to infection, seroma formation and impaired blood supply which results in lower postoperative morbidity and better functional results. Medially based horizontal sternohyoid fascia flap is, due to segmental blood supply of the strap muscles and its indirect perforating vessels, better supplied with blood in comparison to cranially based vertical one. Medial insertion of horizontal fascial flap is more convenient than lateral one due to the possibility of contralateral blood supply. Major drawback of every fascial flap in laryngeal reconstruction is the possible lack of laryngeal wall support and its consequent instability. In order to overcome these problems, we have included platysma along with the investing layer of deep cervical fascia to form soft tissue flap that will meet all requirements present after partial vertical laryngeal resection. If combined musculofascial platysmal flap is to be used as a reconstructive material it should be raised as a horizontal flap of paramedial insertion on the side opposite to primary laryngeal tumor. Functional

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1080 results of laryngeal reconstruction with modified surgical technique using medially based compound musculofascial flap are comparable to those of the original surgical method with sternohyoid fascia published by Krajina and its modification published by Stegnjajic´. We will present surgical technique and functional outcome of our modification in laryngeal reconstruction following partial vertical resections with compound musculofascial flap composed of platysma and investing layer of deep cervical fascia.

A153 Pneumomediastinum: conservative treatment O. Jovicevic*, O. Jovanovic-Nikolic, D. Nesovic Institute for Children’s Diseases, Podgorica, Montenegro Pneumomediastinum represents presence of free air in mediastinum, that can be complicated by development of neck and chest subcutaneus emphysema. We present a case of a boy with pneumomediastinum and neck and chest subcutaneous emphysema that developed as a consequence of a traffic accident, who was successfully treated conservatively. A boy aged 7 years, injured as a pedestrian by a stroke of a bicycle controller at the front region of the neck, admitted at the ICU IBD with presence of subcutaneous emphysema of the neck and the upper part of chest, and without signs of respiratory dysfunction. Neck, lung and chest radiography: In soft tissues of neck, signs of subcutaneous emphysema. There are signs of free air paratracheally, around the heart silhouette but more sinisterly, and mediastinally, with significantly pronounced pattern. CT scan of neck and chest: there is a laceration at the back side of trachea, at C4–C7 level, with no clear signs of tracheal cartilage rupture. Pneumomediastunum with no signs of pneumothorax. The boy was treated conservatively, with three antibiotics. Patient’s condition was stabile after the adequate treatment. Control radiography finding of neck, lung and chest was in significant regression. There are no radiological signs of pneumomediastinum and neck and chest subcutaneous emphysema after 3 weeks. Regardless of conceivable radiological finding of trachea injury with pneumomediastinum, there is a possibility of successful conservative treatment.

A154 Posaconazole for rhinocerebral mucormycosis T. Marom1*, S. Volkenstein2, S. Dezert2, Y. Roth1 Withdrawn

A155 Post-surgical staging is an important prognostic factor in nasosinusal carcinomas. H. Ko¨hler1, L. Kowalski2 1 State University of Campinas, Campinas, Brazil; 2 Hospital A C Camargo, Sao Paulo, Brazil Objective: To report a case series from a single institution to define prognostic factors for nasosinusal carcinomas and a surgical staging system.

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Outcome measurements: Prognostic factors for local and distant relapse of nasosinusal carcinomas. Patients and methods: Retrospective study of patients admitted to a single institution in the period from January, 1985 and December, 2003 and treated with curative intent. Univariate and multivariate survival analysis were performed. Results: Ninety-four patients were evaluated. 64 patients were male. The most frequent site was the maxillary sinus (74 patients). 23 patients were submitted to surgery alone, 42 to surgery and postoperative radiotherapy and 29 to radiotherapy alone. There were 28 local, 10 neck and 17 distant relapses, in 42 patients. In surgically treated patients, T3/T4a stage, extension to the ethmoyd sinus, lymphatic invasion, neural invasion, involved surgical margins and bone invasion were significant prognostic predictors in univariate analysis. In multivariate analysis, involved surgical margins remained significant for survival. Local relapse was affected by involved surgical margins, bone and neural invasion. In a multivariate analysis, involved surgical margins remained significant. No significant factors were found in the radiotherapy group regarding the local relapse or survival. Patients submitted to surgical treatment had a better survival than those treated with radiotherapy (P = 0.0032). Patients were divided in three groups according to surgical extent and margins’ status and this variable was significant for relapse and survival. Conclusion: Surgical treatment should be considered the first option for nasosinusal carcinoma. Post-operative surgical staging may be useful in defining prognosis.

A156 Predictive factors for level VI lymph node metastasis in papillary thyroid microcarcinoma Y. Wang*, Q. Ji, C. Huang, Y. Zhu, L. Zhang Cancer Hospital, Fudan University, Shanghai, Japan Objective: To determine the predictive factors for level VI lymph node (LN) metastasis in thyroid papillary microcarcinoma (PTMC). Methods: We reviewed 86 primarily treated lateral cN0 patients between November 2005 and January 2007 for PTMC by thyroidectomy and elective LN dissection in level VI without comprehensive lateral neck dissection. The following criteria were used to study the predictive value of level VI LN metastasis: sex, age, multifocality of the tumor, thyroid capsular or extrathyroidal invasion (TCI/ETI), tumor size, incidental finding— incidental finding during benign thyroid operation—and enlarged lymph node. RESULTS: In 40 of 86 (46.5%) patients, level VI LN metastasis was found. In univariate analysis, 3 factors were significantly related to level VI LN metastasis: tumor size ([ = 5mm), TCI/ETI and enlarged lymph node ([ = 4mm) (P \ 0.05). Tumor size ([ = 5mm) and TCI/ETI were found to be independent predictive factors for level VI LN metastasis by the multivariate analysis (P \ 0.05). Conclusions: TCI/ETI, tumor size ([ = 5mm) were significantly associated with level VI LN metastasis in patients with PTMC. A elective neck dissection in level VI should be considered particularly in patients with TCI/ETI and a greater than 5 mm tumor. Keywords: Papillary thyroid carcinoma, Microcarcinoma, Level VI, Lymph node metastasis.

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A157 Prevalence and clinical relevance of dysphagia among geriatric hospitalized patients

A159 Primary laryngeal manifestation of acute lymphoblastic leukemia

N. Roper1*, S. De Breucker1, Y. Debethune1, S. Delaere2, T. Pepersack2, S. Hassid1 1 Ear, Nose and Throat and Head and Neck Surgery Department, Erasmus University Hospital, Brussels, Belgium; 2Geriatric Clinic of the Internal Medicine Department, Erasmus University Hospital, Brussels, Belgium

L. Kovac*, M. Bilic*, I. Topic*, B. Bumber*, D. Prgomet* ENT and Head and Neck Department, Clinical Hospital Center Zagreb, Zagreb, Croatia

Introduction: Dysphagia in elderly subjects should not be attributed to normal aging. Aging alone causes mild esophageal motility abnormalities, which are rarely symptomatic. Objectives: We realized a cross-sectional clinical study to assess the prevalence and the clinical relevance of dysphagia among geriatric hospitalized patients. Materials and methods: One hundred subjects consecutively admitted in an acute geriatric department were studied. Patients first underwent comprehensive geriatric assessment which included evaluations of the medical, nutritional, therapeutic, social, functional, and nutritional status. Secondly they benefited of a bedside swallowing evaluation completed by a fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). We searched for independent associations with dysphagia and malnutrition. Results: We obtained statistically significant associations between dysphagia and the incapacity to feed oneself without assistance (Kadz’s Activities of Daily Living) (P \ 0.001), with the fact that the patients were coming from institutions and not from home (P = 0.028) and with the absence of velopharyngeal reflex (P = 0.042). Concerning the FEESST, no variables were independently significantly associated with dysphagia. More results are discussed in the article. Conclusion: Dysphagia must be considered as an alarm symptom, indicating the need for immediate evaluation to define the exact cause and initiate appropriate therapy.

A158 Prevention of side-confusion in surgery on ENT Clinic of Faculty Hospital Ostrava T. Pniak*, P. Kominek Faculty Hospital Ostrava, Ostrava, Czech Republic Wrong side operation is an unacceptable adverse event with unknown epidemiology in Czech Republic. Side verification protocol is a list of procedures, which are performed by healthcare staff. It was created to eliminate the possibility of side confusion in diagnostic and therapeutical procedures in pair organs. Side verification protokol is performed in patient admission to hospital, in rounds and in surgery theatre. It’s principle is a several-step check of patient information in advance of surgery procedure, including side marking. Goal of side verification protocol is to prevent wrong side operation and to improve healthcare in ENT. clinic of Fakulty Hospital Ostrava.

We present a female patient with an airway obstruction due to subglottic T-cell lymphoma as the only manifestation of precursor T-cell acute lymphoblastic leukemia (ALL). To the best of our knowledge, this is the first case of T-cell ALL manifesting as a laryngeal airway obstruction reported in the English literature. The patient underwent carbon dioxide laser resection of the tumorous subglottic mass, with the follow-up during chemotherapy treatment. There was no laryngeal recurrence during the 4-month treatment. The tracheostomy was successfully closed without airway problems; however, the patient died from sepsis due to Pseudomonas aeruginosa infection.

A160 Primary nasopharyngeal tuberculosis R. Prstacic*, M. Jurlina, M. Zizic Mitrecic Department of Otorhinolaryngology Head and Neck Surgery, Clinical Hospital Center Zagreb, Zagreb, Croatia Primary nasopharyngeal tuberculosis is extremely rare entity, especially in non-endemic areas like Europe. We report 48-year-old male patient who presented with the symptoms resembling exacerbation of the previously diagnosed chronic rhinosinusitis. Endoscopic examination of the nose and nasopharynx revealed ulceronecrotic mass which almost completely occupied the left side of the nasopharynx. To rule out the nasopharyngeal carcinoma, multiple biopsies were taken. Histopathological study showed typical giant cell epitheloid granulomas with caseous necrosis. Direct examination after Ziehl– Nielsen staining was also positive on tuberculosis. There was no cervical lymphadenopathy and all pulmonary tests were negative, so the diagnosis of primary nasopharyngeal tuberculosis was established. After 6 months of antituberculous triple therapy, endoscopic examination revealed completely normal nasopharynx. Over the 2 years of follow-up there was no evidence of recurrence.

A161 Primary parotic duct dilation P. Martinez-Seijas*, R. Lobato Perez, U. Bolinaga Zubizarreta, N. Perez Martin, J. Arruti Gonzalez Hospital Donostia San Sebastian, San Sebastian, Spain Introduction: A case of dilatation of Stenon’s duct is described in the right parotid gland. Materials and methods: We describe the clinical and radiological finding in a patient with a painless unilateral round swelling. There was not presented a clinical obstruction findings. The clinical sings,

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1082 pre and post secretion sialography, and magnetic resonance present a locally round cyst in the right parotid gland. A surgical exploration confirms the distended structure and a superficial parotidectomy were performed. In avoid salivary fistulae we were use thrombin glue. Histopathologic examination of the specimen revealed a parotid duct cyst. Diagnosis of primary parotid duct dilation: no recurrence occurs. Discussion: • • • • •

Salivary gland cysts can be benign or malignant. Salivary duct cysts are benign tumours that occur mainly in the parotid gland and represent 10% of all salivary gland cyst. To evaluate a sialographic technique were applied: pre salivary secretion and post salivary secretion. Magnetic resonance imaging (MRI) was used in prior the surgical treatment. Actually there is an increase use of MR sialography. Surgical management due to a superficial parotidectomy. Conclusion:

• • • • •

Primary parotid duct dilation is rare salivary gland pathology, generally occurs in a salivary gland obstruction. Sialography is an important technique in diagnosis of these cases. MRI explores whole salivary gland. Superficial parotidectomy is the recommend treatment. We recommend the use of thrombin glue for avoid salivary fistulae.

A162 Prognostic value of regulatory T cells for early recurrence of head and neck squamous cell carcinoma J. Boucek1*, M. Chovanec1, M. Kuchar1, T. Mrkvan2, V. Boucek5, M. Hladikova4, J. Betka1, T. Eckschlager3, B. Rihova2 1 Department of Otorhinolaryngology, Head and Neck Surgery, The First Medical Faculty of The Charles University, Prague, Czech Republic; 2Institute of Microbiology ASCR, v.v.i., Videnska 1083, Prague 4, 142 20, Czech Republic; 3Department of Paediatric Haematology and Oncology, The Second Medical Faculty of the Charles University, Prague, Czech Republic; 4 Department of Medical Informatics, The Second Medical Faculty of the Charles University, Prague, Czech Republic; 5Department for Haematology and Blood transfusion, Hospital of Rudolf and Stephania Benesov, Benesov, Czech Republic Regulatory T cells (Treg, CD4+ CD25+ Foxp3+) were described as one of the critical factors for regulation or inhibition of effective anticancer immune response and, consequently, the prognosis and survival for different types of tumors. Increased Treg frequency in the peripheral circulation was proven in correlation with the progression of Head and Neck Squamous Cell Carcinoma (HNSCC). We examined Treg from periphery blood of patients (112) with HNSCC before the start of anti-tumor therapy and the infiltration of Treg in specimens from primary tumors and from metastases to the neck lymph nodes in a group of patients (25) who underwent surgery. The erythrocyte count and hemoglobin level were decreased while the regulatory T cells were increased in the group of patients with early recurrence of the disease (P = 0.04). The percentage of CD8+ cells

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 increased and CD4/CD8 ratio decreased with tumor grade. B lymphocyte proportion was decreased in patients with locoregional metastases (N+ stage). Treg and CD4+ cells were increased while NK cells were decreased in HNSCC patients compared to healthy controls. The number of Treg in specimens from metastatic neck lymph nodes was higher (P \ 0.005) in comparison with neck lymph nodes without metastatic extension. Our results show that examination of these parameters could be helpful for prognostication in HNSCC patients and aid improvement of treatment strategy. The research was supported by IGA MZ CR (grant No. 8883-3), NPV 2B06106 and MSM 0021620813.

A163 Quality of life after different treatment modalities in long-term survivors of oropharyngeal carcinomas M. Pearson*, A. Gurr, S. Dazert, A. Minovi Department of Otorhinolaryngology, Head and Neck Surgery, Ruhr-University, Ruhr, Germany Background: The aim of this study is to assess quality of life (QoL) outcomes of patients after different treatment modalities for oropharyngeal carcinomas: surgery and adjuvant radiotherapy (SRT) and primary chemoradiation therapy (CRT). Methods: In a cross-sectional study QoL was evaluated with two validated questionnaires: the global EORTC-QLQ-C30 and the headand neck-specific EORTC-QLQ-H&N35. Results: The mean age at the time of investigation was 59.4 years. There were 67 patients in the SRT and 15 patients in the CRT group. Concerning the EORTC QLQ-C30 questionnaire we found a significant difference in physical and cognitive functions (P = 0.03, and 0.02, respectively). Patients in the SRT group reached higher mean values in these two categories, indicating higher QoL. The results of the specific EORTC QLQ-H&N35 did not show significant differences between the two groups. Conclusions: Quality of life after curative therapy of oropharyngeal carcinoma can generally be regarded as satisfactory.

A164 Questions behind malignancies of the head and neck advances on biology (understanding, treatment, follow up) G. Szalai1*, J. Molna´r2, P. Grandics3 1 MONMED, 1056, Budapest, Hungary; 2Institute of Medical Microbiology and Immunobiology, University of Szeged, Szeged, Hungary; 3A-D Research Foundation 5922 Farnsworth Ct, Carlsbad, CA 92008, USA Over half a million tumors of the head and neck are malignant each year diagnosed worldwide a year, about 4,000 of them in Hungary. 9/10 of them are of squamous origin cancer, presents first with stage III or IV disease. Survival rate an overall 5-year below 50% remained unchanged. Recurrence in 30% and distant in 25% appear. The high mortality and morbidity encourage the pursuit of alternative therapeutic strategies. The immune system of advanced stage head and neck cancer (HNC) patients is frequently suppressed. Poor immune function has been correlated with poor clinical outcome. Apoptosis can be deficient in the event of a weakened immune system, the causes of which are

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 multifactorial. Some autoreactive T cells suffer genomic damage in this process, but manage to survive. The resulting cancer stem cell still retains some functions of an inflammatory T cell, so it seeks out sites of inflammation inside the body. Due to its defective constitutive production of inflammatory cytokines and other growth factors, a stroma is built at the site of inflammation similar to the temporary stroma built during wound healing. Immunotherapeutic strategies have been previously attempted in an effort to enhance immune function and improve survival. Covalently linking proteins and cytokines could have enormous potential for the in vivo manipulation of the immune system. Human carcinoembryonic antigen (CEA) in HNC is not widely recognized. Recent studies evaluated CEA in preclinical and clinical levels as a target for specific immunotherapy against HNC.

A165 Rabdomyoma of the tongue C. Evaggelopoulos, V. Lachanas*, C. Gantas, P. Pavlidis, C. Makrypidis, E. Theos, E. Gkletsou, T. Apostolidis Otorhinolaryngology, Head and Neck Surgery Department, School of Medicine, University of Thessaly, Larissa, Greece Rhabdomyoma is a rare soft tissue benign tumor of skeletal muscle origin classified into cardiac and extracardiac types based on its location. Extracardiac rhabdomyoma is further classified into adult, fetal and genital rhabdomyoma and rhabdomyomatous mesenchymal hamartoma. Adult rhabdomyoma is exceedingly rare, and most commonly arise in the head and neck region. It grows most frequently as a solitary mass but may be multinodular or multifocal. We present a case of a 70 years old male patient who presented with a 2-year history of progressive dysphagia. Clinical examination revealed a mass in the base of his tongue extending to hypopharynx. CT and MRI imaging showed a soft tissue mass of the tongue base which extended to the left side of hypopharynx without presence of lymphadenopathy. The mass was excised through a median pharyngotomy approach and resection of the hyoid and histology showed the mass to be an adult type rhabdomyoma. The postoperative period was uneventful and the patient is under regular follow up for 3 years now with no sign of recurrence. The signs and symptoms of rhabdomyoma in the head and neck are completely non-specific and depend on the size and location of the tumor while malignant degeneration has not been reported so far. Due to its high recurrence rate complete surgical excision, as in our case, is indicated.

A166 Radiofrequency surgery of the tonsils in adults Z. Balatkova´1*, J. Plza´k0, J. Astl1, P. Lasˇtu`vka1, J. Betka1 1 Department of Otorhinology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University, Prague, Czech Republic; 2Institute of Anatomy, 1st Faculty of Medicine, Charles University, Prague, Czech Republic;

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Center of Cell Therapy and Tissue Repair, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic Radiofrequency surgery is one of popular surgical methods that are used for treatment of hypertrophy of palatal tonsils. Tonsillar capsule and partially also lymphoid tissue is preserved during the surgery. We treated 29 patients (6 males and 23 females; median age, 25.2 years; age range 12–45 years) for tonsillar hypertrophy from December 2005 until December 2008. They underwent radiofrequency surgery of the tonsils under local anesthesia. For objectification of the effect 3D sonography volume measurement was performed before and two months after surgery. General health, pain, and feeding status were monitored by questionnaire postoperatively. The average volume reduction of the tonsil in all treated patients was 26%. There were observed low deterioration of general health, pain, and feeding status. Radiofrequency surgery under local anesthesia is effective, safe and well tolerated operative technique in treatment of palatine tonsils hypertrophy in adults. Supported by the grants NR 9474-3 and NPV 2B06106.

A167 Radiofrequency treatment of tonsillar and turbinate hypertrophy in children with sleep: disordered breathing G. Khandanyan*, A. Shukuryan* ENT Department, Medical Center « Erebuni », Yerevan State Medical University, Yerevan, Armenia Objective: Initial evaluation has shown that temperature-controlled radiofrequency submucosal volumetric tissue reduction (RVTR) effectively treats obstructive symptoms of tonsillar and inferior turbinate hypertrophy with minimal associated discomfort and rapid return to normal activity and diet. !Methods: We followed 80 children, 5–15 years of age, with a case history of oral breathing, snoring and night time apnoeas. The patients presented with tonsillar and inferior turbinate hypertrophy and no septal deformity. All the patients underwent RVTR (Ellman Dual-Frequency IEC-II). This surgery procedure was performed with different combination. RVTR of tonsils and inferior turbines were performed in a 45 children of 80. RVTR of tonsils were performed in 16 patients and RVTR of inferior turbines was performed in 19 children. Results: All children were reviewed on the 1st, 7th, and 14th day and 1 month, 3 months, 6 months and 1 year after surgery. Primary outcomes shows sustained increases in oropharyngeal size in 72 (90%) patients, snoring reduction of 74 (92.5%). 75 children (93.75%) significantly improved their nasal breathing postoperatively. All these changes improved sleep quality in all patients [Epworth Sleepiness Scale (range 0–24)]. Secondary outcomes include postoperative pain, speech and swallowing problems. 31 (38, 75%) reported no pain, 49 (61, 25%) had mild to moderate pain. No one reported problems with speech and swallowing. Conclusion: The results of this study demonstrate that RVTR is a safe, effective method for the treatment children with sleep—disordered breathing, for reduction of turbinate and tonsillar hypertrophy in children.

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A168 Rapid superselective cisplatin infusion with concomitant radiotherapy for base of tongue cancer

procedure. In the remaining 3 decaniulation was unsuccessful. Voice produced by neoglottic is hoarse but process of communication has been maintained in all cases. Deglutition seem to be weakness aspect of this surgical technique.

A. Homma*, F. Suzuki, S. Taki, T. Mizumachi, S. Kano, N. Oridate, S. Fukuda Department of Otolaryngology Head and Neck Surgery, Graduate School of Medicine, Hokkaido University, Hokkaido, Japan

A170 Relationship between vascular endothelial growth factor and Notch1 expression and lymphatic metastasis in tongue cancer

Purpose: The purpose of this study was to evaluate the efficacy of rapid superselective cisplatin infusion with concomitant radiotherapy (RADPLAT) for patients with base of tongue cancer. Patients and methods: From 2001 to 2007, 14 patients with untreated, base of tongue cancer were given superselective intraarterial infusion of cisplatin (100 mg/m2/week) with simultaneous intravenous infusion of thiosulfate to neutralize cisplatin toxicity and conventional extra-beam radiotherapy (65–70 Gy). Eleven patients had squamous cell carcinomas and three patients had adenoid cystic carcinomas. Primary tumor stages included T2 (3 cases), T3 (4) and T4a (7). N stages included N0 (5), N1 (1), N2b (7) and N2c (1). Results: The median follow-up period was 35.7 months (range 18– 96 months). All patients completed radiotherapy without interruption. No patient died as a result of treatment toxicity. Four patients received salvage neck dissection because of persistent neck disease after the therapy. Twelve patients are surviving without disease but two patients are alive with disease. One had primary recurrence and another had lung metastasis. All patients without primary recurrence are able to have oral intake without feeding-tube support. Conclusions: We confirmed the efficacy of RADPLAT, which can concentrate the attack of supradose cisplatin on locoregional disease. Although the treatment regimen was intensive, acute toxicity was manageable in the majority of patients and all patients without primary recurrence are able to take oral intake after the therapy. We consider that the base of tongue cancer is a good indication to be treated by RADPLAT.

A169 Reconstructive laryngectomy: possibility of larynx preservation in patients with larynx cancer M. Leszczyn˜ska*, W. Szyfter, M. Wierzbicka ENT Department, University of Medical Sciences, Poznan, Poland Organ preservation strategy in the cancer of the larynx includes the chemioradiotherapy or radiotherapy. From the surgical point of view this strategy colud be understand as a functional surgery with the preservation of some part of the larynx. In University ENT Department in Poznan˜ during last 10 years 1,620 different types of larynx surgery due to the cancer has been performed. We present the group of 176 cases larynx cancer using different types of reconstructive laryngectomy like transglottic laryngectomy modo Sedlacek–Tucker 23 patients, modo Calearo 83, the supracricoid laryngectomy with CHEP 65, with CHP 4. Results: Local recurrence we observed in 7 cases In this cases total laryngectomy was performed. 14 patients had reccurences in the neck, neck dissection was carried out, followed by adjueant XRT. We decaniuleted 166 patients retracheotomy was performed in 10 cases due to neolarynx stenosis. Then in 7 of them was decaniuleted after laser

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B. Chun*, Y. Joo, M. Kim, D. Sun, K. Cho Department of Otolaryngology H&N Surgery, The Catholic University of Korea, Seoul, Korea Objective: To determine the role of angiogenesis in lymph node metastasis and the depth of invasion in early tongue cancer. Study design: Retrospective analysis. Subjects and methods: The study included 51 subjects with tongue cancer. Immunohistochemical staining for vascular endothelial growth factor, Notch1, and Notch3 was performed. Microvessel density was evaluated by counting the number of CD34-stained microvessels in each pathologic specimen. Results: Significant correlations were found between vascular endothelial growth factor and Notch1 expression and cervical lymph node metastasis (P = 0.020 and P \ 0.009, respectively), tumor depth of invasion (P = 0.001 and P \ 0.001, respectively), and microvessel density indicated by CD34 staining (P = 0.001 and P \ 0.001, respectively). Nodal metastasis (P = 0.022), T stage (P = 0.002), and positive VEGF expression (P = 0.044) were statistically significant prognostic factors for disease-specific survival. Conclusion: Vascular endothelial growth factor and Notch1 expression are significantly related to cervical lymph node metastasis and depth of invasion in tongue cancer patients.

A171 Results of partial laringectomy after failure of radiotherapy H. Mocanu1*, A. Marcu1, A. Agache2, C. Stan2, L. Luhan2, D. Manu1 1 Titu Maiorescu University, Bucharest, Romania; 2Ilfov Clinical Emergency Hospital, Bucharest, Romania Between the year 2000 and 2008 around 50 cases of laringeal neoplasm that underwent radiotherapy and registered little or no response to it, were admitted to our clinic in order to find a surgical and as less mutilant as possible solution to the problem. Keeping in mind that the overall attitude of todays surgeons is to preserve as much of the functional properties of different organs in the attempt of curing the disease, we chose for these cases an approach through partial laringectomy. The techniques of partial laringectomy used were diverse much as the locations of the tumors, as it will be pointed out in our presentation. Our goal is to present our surgical attitude for each type of tumoral location, our results and also to prove that for a specialized surgeon, trained for this type of interventions, such cases of failed radiotherapy can also be solved by partial laringectomy with preservation of functional larynx. We also intend to present results of large tumors who underwent partial laringetomies and showed good results with consequitive radiotherapy.

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A172 Risk and prognostic factors of tumors of oropharynx and oral cavity: the role of HPV J. Klozar1*, E. Rotnaglova1,2, E. Koslabova1,2, E. Hamsikova2, M. Salakova2, J. Smahelova2, R. Tachezy2 1 Department of Otolaryngology Head and Neck Surgery, 1st Faculty of Medicine, Charles University, Prague, Czech Republic;2Department of Experimental Virology, Institute of Hematology and Blood Transfusion, Prague, Czech Republic The aim of the study is to find out the risk factors of oropharyngeal and oral tumors and to identify prognostic factors of these tumors with regard to HPV status. Enrolled were 221 patients with oral/ oropharyngeal cancer and 196 healthy controls. HPV DNA detection and typing were performed by means of PCR and reverse line blot hybridization. Risk factors and clinical data gathered prospectively were analyzed together with the presence of HR HPV in the tissue. The exposure to tobacco and alcohol were the most significant risk factors. HPV DNA was detected in 61.6% of tumor tissue samples. The prevalence of HPV DNA was lower in oral than in oropharyngeal tumors, and higher in never smokers and never drinkers. In cases HPV DNA presence was not related to gender, age, number of lifetime sexual partners or practice of oral–genital sex, size of tumor or presence of regional metastases. HPV positive patients had significantly better both overall and disease specific survival rates then HPV negative patients. Analyses showed that prognostic factors were the presence of HPV in the tumor, extracapsular spread and tumor size. The most important risk factors are tobacco and alcohol consumption. A distinct subgroup of tumors has etiological relation to HPV. HPV was the most significant prognostic factor and possibly should be considered in treatment decisions. Supported by grant NR/9466-3 of the Internal Grant Agency of the Czech Ministry of Health.

A173 Risk factors of occurrence of pharyngocutaneous fistula formation after total laryngectomy Z. Cada*, M. Chovanec, J. Klozar Department of Otorhinolaryngology, Head and Neck Surgery, Charles University, 1st Faculty of Medicine, Prague, Czech Republic Total laryngectomy (LET) is with increasing frequency performed as salvage procedure. In general it is known that previous oncological treatment is associated with higher rate of complications particularly pharyngocutaneous fistulas (PF). The aim of the study is to analyze the risk factors for PF formation. The factors studied were: age, tumor size, presence and extent of lymphatic metastasis, type of surgery, histopathological markers (keratinization, lymfangioinvasion, angioinvasion, extracapsular spread, grading), experience of the surgeon and previous oncological therapy. We investigated which of these factors were the independent risk factors for the fistula formation. We also tried to find out whether the occurrence of complication influences the prognosis. Materials and methods: Retrospective study was done on 169 patients, who underwent LET in the years 2002–2007. Statistical analysis was performed. P values, odds ratios were calculated and

1085 values were adjusted for other parameters by forward stepwise regression model. Results: The rate of pharyngocutaneous fistulas in postoperative course in primary LET was 15.6%. It was significantly higher (34.1%) in the group of patients with previous oncological therapy. Multivariate analysis demonstrated that surgeon0 s experience (surgeons younger 35 years had statistical higher occurrence of PF than the surgeons above 35 years) and the type of previous treatment were the two independent prognostic factors of fistula formation (P \ 0.05). Conclusion: The prognostic factors of fistula formation were the experience of the surgeon and the treatment previous to surgery. The occurrence of a fistula in the postoperative course did not influence the survival. Supported by the grant NPV 2B06106

A174 Role of Th17 cells in head and neck cancer R. Kesselring*, A. Thiel, R. Pries, B. Wollenberg Department of Otorhinolaryngology, University of Lu¨beck, Lu¨beck, Germany The discovery of a new population of CD4+ T helper cells, in addition to the traditional Th1 and Th2 subsets, that selectively produce IL-17 has provided new insights into immune regulation and host defence. This lineage of CD4+ T helper cells, which has been termed Th17 cell, indeed plays an apparently critical role in the pathogenesis of a diverse group of autoimmune. But less is known about the role of Th17 cells in the pathogenesis and development of cancer. A combination of TGF-b; and IL-6 induce Th17 cell lineage commitment via expression of transcription factor RORgammat. Th17 cells and induced T regulatory cells are in reciprocal position in the T cell lineage commitment governed by TGF-beta and IL-6. IL-17 is a highly inflammatory cytokine with robust effects on stromal cells in many tissues as well as on endothelial and epithelial cells, synoviocytes and myeloid cells and induces the production of many other cyto- and chemokines such as IL-6, 8 and 1b, G-CSF, GM-CSF, TGF-b, TNF-a, GRO-a and MCP-1. The aim of our study was to assess the levels and the functional state of Th17 cells and their crosstalk with induced regulatory T cells in patients with head and neck cancer. Cells were phenotyped by flow cytometry, the expression of cytokines and transcription factors was evaluated by multiplex assays and their function was evaluated by proliferation assays, migration assays and flow cytometry. Our results indicate that the function of Th17 cells is impaired in patients with HNSCC.

A175 Sensitivity of fine needle aspiration (FNAC) in the management of discrete thyroid nodules: a large cancer centre experience H. AL-Reefy*, S. Balasubraminum, K. Kapoor, M. Black, D. Mitchell East Kent Hospitals NHS Trust, Canterbury, Kent, UK Fine-needle aspiration cytology (FNAC) of thyroid nodules has become the primary diagnostic tool in evaluation of discrete thyroid nodules. However, the diagnostic utility of thyroid cytology may be

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1086 limited by the presence of atypical cytological patterns. The purpose of this study was to evaluate the accuracy and adequacy of thyroid fine needle aspiration cytology and correlate the results to the final histological diagnosis as a gold standard. A retrospective review of 76 patients who underwent FNAC and subsequent surgical excision with a histological diagnosis of thyroid nodules (between June 2006 and January 2008) at a large cancer centre. of the 76 patients with FNAC, histological evaluation revealed 37 malignant and 39 benign lesions. The cytological findings were true negative in 56%, true positive in 24%, false negative in 24%, and a false positive in 46% when trying to detect a malignant tumor. The sensitivity and specificity were 65 and 91% respectively. As a preoperative diagnostic tool for surgical excision of thyroid nodules FNAC is less reliable than it is widely accepted.

A176 Serum levels of RCAS-1 as prognostic marker in head and neck squamous cell carcinoma M. Brunner1*, B. Erovic1, G. Heiduschka1, S. Frantal2, D. Thurnher1 1 Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria; 2 Core Unit for Medical Statistics and Informatics, Medical University of Vienna, Vienna, Austria RCAS-1 has been found to be a good prognostic marker in a number of different malignancies. Furthermore it is known to be overexpressed in oral squamous cell carcinoma. We therefore analysed the potency of RCAS-1 as a biomarker in the serum of patients with head and neck squamous cell carcinoma in a prospective study. We included 60 patients and 31 controls. Blood samples were taken at the time of diagnosis and after 3 and 12 months and ELISA was performed. RCAS-1 levels were compared between patients and controls and correlated with outcome and clinical data. Surprisingly median RCAS-1 levels were almost identical between tumor patients and controls. However, we nevertheless found a statistically significant tendency for patients with lower RCAS-1 levels to have longer disease-free (uni- and multivariate analysis) and overall (univariate analysis) survival. Longitudinal analysis did not reveal a correlation between RCAS-1 levels and response to therapy or the presence of recurrence. Our conclusion is that RCAS-1 could be a clinically useful diagnostic and predictive tool in head and neck squamous cell carcinoma although larger studies will be required to confirm our initial results.

A177 Severe blunt external laryngotracheal trauma: surgical outcome R. RL Ahmad1*, W. W Leman1, K. Abdullah1, S. Razali1, Z. Asya’ari1, N. Kamarudin2 1 Department of Otolaryngology-Head and Neck Surgery, International Islamic University Malaysia, Kuantan, Malaysia; 2Department of Diagnostic and Imaging, Tengku Ampuan Afzan Hospital Malaysia, Kuantan, Malaysia

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Blunt external laryngotracheal trauma is rarely encountered in clinical practice. Most of the time, the first attending doctor overlooks this injury. Surgical management for this trauma is complicated, since there is no common management approach for this potentially life-threatening injury. It is important that this injury to be identified early as delay in surgical intervention may result in poor airway and speech outcome. The aim of surgical reconstruction is to minimize the debilitating morbidity from the trauma by restoring as much as possible the main laryngeal functions of airway and speech. We reviewed four cases of severe blunt external laryngotracheal trauma and assessed the outcome of the surgical interventions. One patient had associated cervical trauma and none of them had concomitant esophageal injury. All patients made a good recovery in term of airway function, but most of them except one developed reduced speech function. The technique of surgical reconstruction is highlighted in this report. The surgical treatment depends on the site of injury either in the larynx or tracheal. In both situations stenting are needed to help normal healing and re-epithelization to take place. In conclusion, prompt recognition and airway controlled are required in laryngotracheal trauma. Surgical emphysema is an important hallmark that should alert the attending physician to the possibility of severely laryngotracheal trauma. Immediate surgical intervention with appropriate surgery in this problem may result in favorable outcome. Keywords: Laryngotracheal trauma, Airway injury.

A178 Short-term outcome of uvulopalatopharyngoplasty in obstructive sleep apnea syndrome patients: comparison of changes of subjective symptoms on sleep quality D. Kim1, C. Yeo 1 Dept ORL, School of Medicine Keimyung University, Daegu, South Korea Objectives: Uvulopalatopharyngoplasty (UPPP) is a most frequently performed surgical treatment of obstructive sleep apnea syndrome (OSAS). The sleep quality is an important influence in the perfomance on obstructive sleep apnea syndrome patient. This study was performed to evaluate the sleep quality after postoperative followup. Methods: Fifty-five patients presenting snoring or other symptoms of OSA were evaulated retrospectively at the sleep disorder clinic in Keimyung University, Dongsan Medical Center were included in this study. All patients completed an overnight polysomnography and several sleep questionnaires. The sleep questionnaires included the Stanford Sleepiness Scale (SSS), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), and Beck Depression Inventory (BDI). The same questionnaires were completed by all patients again after 1 month of uvulopalatopharyngoplasty, and the change of sleep questionnaires scores were assessed. Results: There was a significant difference of SSS, ESS, PSQI, and BDI after treated by UPPP in OSAS patients. Conclusions: Our study found that in short-term evaluation of the sleep quality after UPPP of OSAS patients, UPPP may improve the sleep quality and depressive symptoms in OSAS patients.

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A179 Sleep apnea disease M. Kirjas* ENT Department, Clinical and University Center-Skopje, Skopje, Macedonia The start of sleep apnea diagnosis in Macedonia was on the end of 2007. It was so difficult ‘like holding a tiger by the nail’. Patients were multidisciplinary followed up. 79 patients were randomized: 28 women, 47 men and 4 kids with full night polysomnography. Four kids with OSA (AHI 13.7–21.2) were evaluated before and after the surgery (tonsilloadenoidectomy,septoplasty). In adults co-morbidities: HTA, stroke, uvula hypertrophy, nasal polyposis, they were also evaluated before and after the surgery if they need it, or before and after 1 year CPAP therapy. Some patients had contraindications of use nCPAP like cardial insufficiency, cardiac arrythmias, malignancy.

A180 Solitary abducens nerve palsy secondary to isolated sphenoid aspergilloma A. Trinidade1, M. Shakeel1*, A. Chapman2 1 Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK; 2Department of Pathology, Aberdeen Royal Infirmary, Aberdeen, UK Objective: To increase awareness of isolated fungal sphenoid disease as a differential diagnosis for solitary abducens nerve palsy. Study design: Case report and literature review. Subject: An 80-year-old man presenting with right-sided abducens nerve palsy secondary to an aspergilloma within his sphenoid sinus, who made a full recovery following endoscopic trans-ethmoidal sphenoidotomy and disease clearance. Conclusion: First presentation of this rare entity is usually in the form of one of its potential complications. This can be varied due to the anatomical proximity of the sphenoid sinus to the orbits and the cavernous sinuses. Solitary abducens nerve palsy can be a sensitive indicator of its occurrence. Early recognition and treatment of this condition are crucial in preventing permanent disability.

A181 Sore throat complicated by first web space infection: can we call it Lemierre’s syndrome? M. Shakeel*, N. McCluney, L. Li, J. Newton Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK Lemierre’s syndrome is caused by acute oropharyngeal infection with septic secondary thrombophlebitis of the internal jugular vein and metastatic infection. Fusobacterium necrophorum is the most commonly implicated aetiological agent. The authors present the case of a healthy young man presenting with a history of general malaise and sore throat who developed septic metastatic complications in the left upper limb. He made a complete recovery after treatment with a combination of parenteral antibiotics and a multidisciplinary

1087 approach. Early ultrasound scanning of the neck and blood cultures are advocated to diagnose this potentially fatal condition. Management involves a high degree of clinical suspicion for this often ‘forgotten’ condition and treatment is further discussed in the article.

A182 Spheroids generated from head and neck cancer cell lines possess cancer stem-like cells characteristics C. Chen1*, A. Kaufmann2, M. Hummel3, T. Hoffmann4, A. Albers1 1 Department of Otolaryngology, Head and Neck Surgery, Charite, Mitte, Berlin; 2Department of Gynecology, Charite, Mitte, Berlin; 3Department of Pathology, Charite, Mitte, Berlin; 4Department of of Otolaryngology, Head and Neck Surgery, University Du¨sseldorf, Du¨sseldorf, Germany Introduction: Malignancy of head and neck squamous cell carcinoma (HNSCC) has been related to the presence of cancer stem-like cells (CSC). Recurrence and metastasis after radiochemotherapy might partly be due to resistant CSC. Aldehyde dehydrogenase isoform 1 (ALDH1) identifies CSC, stem and progenitor cells, and contributes to chemoresistance. Nodal is an embryonic morphogen maintaining pluripotency of human embryonic stem cells and is highly expressed in melanoma and breast cancer. Methods: HNSCC-lines UD-SCC4, UD-SCC5 and UD-SCC6 were used to generate spheroids in supplemented serum-free medium to enrich for CSC. 3rd generation spheroids were characterized by immunochemistry, invasion and single cell expansion assays. Results: All cell lines formed spheres that could self-renew, be repassaged, adhered to plastic, and grew to confluency. HNSCC from spheroids expressed ALDH1 while in parental monolayer cell lines expression was low. Nodal was found highly expressed in spheroids ([95% in UD-SCC4) compared to controls. Spheroid-derived cells exhibited higher invading activity than parental controls. The invasion index for UD-SCC4, UD-SCC5 and UD-SCC6 was 2.3, 5.1 and 6.9, respectively. Single cells isolated from spheroids regrew to spheroids in 17.1% (UD-SCC4), 39.1% (UD-SCC5) and 19.3% (UD-SCC6) (parental control: 0-6.67%). Discussion: Putative CSC can be isolated and expanded by culture techniques from HNC-lines by generation of spheroids. These cells show expression of CSC markers ALDH1 and Nodal and may be further characterized. These CSCs have higher invading activity than the parental monolayer cancer cell lines, which may imply relevance for cancer metastasis.

A183 Spontaneous fracture of an ossified stylohyoid ligament: case presentation ´ va´ri1*, P. Magyar2, G. Szentma´rtoni2, G. Re´pa´ssy1 A. O 1 Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Semmelweis University, Budapest, Hungary; 2 Department of Radiology and Oncotherapy, Semmelweis University, Budapest, Hungary

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1088 The totally ossified stylohyoid complex is an uncommon condition, and its spontaneous fracture is a rarity. The authors give an overview of the etiology and the differential diagnosis of this entity. They emphasize the value of the multi slice CT scans with postprocessing methods (i.e. 3D volume rendering) in the diagnostic process, beside the conventional radiographs. The authors present a case of a 48 years old male patient with an acute onset dysphagia after swallowing. He complained of pain radiating to the neck and ear of the left side and sensed crepitation by swallowing. With physical examination there was found an elongated styloid process on the left side. X-ray pictures and CT scans showed a completely ossified stylohyoid complex (styloid process, stylohyoid ligament, lesser horn of the hyoid bone) with a fracture of the stylohyoid ligament and 3 articulations. The healing of the patient was spontaneous, surgery was not indicated.

A184 Spontaneous internal jugular vein thrombosis: case report and literature review M. Shakeel*, J. Kynaston, N. McCluney, K. Ah-See Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK Introduction: Internal jugular vein (IJV) thrombosis is a rare but potentially fatal condition. First described in 1912 as a complication of peritonsillar abscess it is now known to have a varied aetiology. The leading cause of IJV thrombosis is the use of the IJV for venous access and central venous catheterisation. Objective: We report a rare case of idiopathic internal jugular vein thrombosis in an otherwise healthy adult woman. Method: Case report and literature review. Results: A 60-year-old woman was admitted with a 5-day history of an enlarging right sided neck swelling that was initially associated with redness and pain. On examination her observations were normal. There was a tender, soft, diffuse swelling along the length of the right sternomastoid muscle. The overlying skin was mildly erythematous. The USS showed occlusive thrombosis of right IJV. Blood cultures, a chest X-ray (CXR) and computed tomography (CT) chest were all normal. The patient was put on warfarin. All the subsequent investigations by haematology team were normal. Conclusion: IJV thrombosis is an important differential diagnosis in neck swelling. Along with various other factors, it can also occur as a complication of head and neck malignancy, and rarely can be the first manifestation of the malignancy. On other occasions a specific aetiology is never found. Multidisciplinary team approach is required to manage the patient efficiently.

A185 Stem cell characteristics of polyposis nasi A. Hagge, S. Reers, R. Pries, B. Wollenberg* Department of Otorhinolaryngology, University of Lu¨beck, Lu¨beck, Germany Polyposis nasi represents a benign neoplasm of the nasal mucosa, which leads to a decreased breathing capacity and reduced olfaction. The pathogenesis and the molecular mechanisms of polyposis nasi are still almost unknown. It is most likely that stem cells are directly involved in the developmental processes. In this work, we focus on the identification and characterization of potential stem cells in polyposis nasi and the

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 molecular regulation of growth and regeneration. Single cell suspensions of polyposis nasi were analyzed by flow cytometry concerning their surface characteristics as well as their proliferation and selfrenewal capacities. Healthy nasal mucosa was used as an internal control. Our results demonstrate the identification of different cell subsets in polyposis nasi. These cells show different expression levels of potential stem cell markers CD44 and CD59 and strong similarities to solid HNSCC tissue samples. The different populations were isolated using a fluorescent activated cell sorter and our investigations demonstrate significant differences concerning proliferation and ‘selfrenewal’. Our data provide novel insights in the origin of polyposis nasi as well as in the role of stem cells in benignant and malignant neoplasms of the head and neck.

A186 Sternotomy for retrosternal goitres: length of stay and complications R. Simo*, J. Jeannon, K. Harrison-Phipps, C. Ong, S. Connor Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK Introduction: Sternotomy for the excision of retrosternal goitres is rare. It is often associated with prolonged length of stay, high morbidity and potential mortality. The aim of this study is to analyze the length of stay (LOS) and complications of patients who have undergone a combined cervical and sternotomy for the excision of retrosternal or intrathoracic non-toxic goitres. Methods: Retrospective review of patients who underwent thyroidectomy in our unit between January 2000 and November 2008. Eleven patients required a combined cervical and sternotomy approach. All patients were evaluated with ultrasound-guided fine needle aspiration, CT scan of the neck and chest. Results: of the 11 patients, 5 were females and 6 were males. Age ranged between 43 and 78 years with a mean age of 58.5. Patients required sternotomy due to: Giant intrathoracic extension (1), complex anatomical distribution (3), retroesophagic and retrotracheal extension (4) and previous failed cervical approach (3). LOS ranged between 3 and 10 days with a mean of 6 days. Complications included 3 pneumothorax treated drain insertion, 2 temporary hypocalcaemia, 2 temporary recurrent laryngeal nerve paresis, 1 keloid scar and one axillary vein thrombosis that recovered with conservative measures. Conclusions: The optimal management of retrosternal goiters requires careful evaluation and planning. CT scanning will allow adequate surgical planning. Complications are expected due to the complexity of the surgery but these will not impact significantly on the length of stay. A multidisciplinary team approach between the head and neck and thoracic surgery teams is essential.

A187 Sterolithographic models in orofacial reconstruction surgery P. Martinez-Seijas*, J. Arruti Gonzalez, U. Bolinaga Zubizarreta, N. Perez Martin, R. Lobato Perez Hospital Donostia San Sebastian, San Sebastian, Spain Objectives: We present the medical application of stereolithographic anatomical models to enhance diagnosis, treatment plans and surgical simulation.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Materials and methods: We discuss their use to facilitate individualization and better results in orthognatic surgery, reconstructive microvascular free flap surgery (fibular apropiate osteotomies and 3D mandible location) and placement of craneofacial implants. Results: We present representative cases on orthognatic surgery and reconstructive surgery. Conclusions: Models have demonstrated that improve diagnostic and surgery planning. In microvascular free flap surgery, we can recreate the shape, size and configuration of the bone graft. They decrease operating time and particularly applicable to complex craneomaxillary deformities.

A188 Superficial parotidectomy: the influence of age on postoperative facial nerve function A. Al-Adhami2, M. Shakeel1*, A. Canna2, A. Trinidade1, A. Hussain1 1 Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK; 2School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK Introduction: Site of lesion within the parotid gland, its underlying histology and extent of parotidectomy influence post-operative facial nerve function. Age was not shown by some to influence facial nerve function post-operatively. Aim: To evaluate the association between age and postoperative facial nerve function after superficial parotidectomy. Study design: Retrospective chart review. Ethics: Approved by institutional Clinical Effectiveness department. Method: Comparison of two cohorts undergoing surgery between 1996 and 2007: those younger than 45 (group 1) with those aged 45 and above (group 2). Data were collected on demographics, extent of surgery, pathological diagnosis, lesion site at operation, and the presence of facial nerve palsy at follow-up. SPSS v16 was used for data storage and analysis. Results: A total of 201 patients were identified (69% underwent complete superficial and 31% had partial superficial parotidectomy). There was equal gender distribution with a mean age of 53 years (4–84). There were 58 patients in group 1 and 143 in group 2. The overall incidence of facial nerve palsy was 26%. When compared with group 2 however, group 1 showed a significantly lower incidence of facial nerve palsy (31.5 and 12.1% respectively, P \ 0.01). Between the two groups, there was no statistical difference in the extent of superficial parotidectomy, the pathological category or the site of the lesion (P = 0.69, 0.07 and 0.47 respectively). Conclusion: After adjusting for the extent of resection, the pathological category and the site of parotid lesions, the facial nerve dysfunction increased significantly in those aged 45 and over.

A189 Surgery of the lop-ears A. Antohi*, S. Vetricean, I. Antohi, A. Bajureanu, E. Cernolev Department of Otorhinolaryngology, University of Medicine and Pharmacy Nicolae Testemiþanu, Chisinau, Republic of Moldova

1089 Goal of the work: To propose a new efficient method of surgical correction of bat-ears which will able to minimize surgical trauma and possible complications after surgery. Materials and methods: We performed 39 surgeries for correction of auricles: 27 patient with congenital lop ears and 12 with posttraumatical deformations of auricles. Outcomes: All patients who underwent otoplasties following our method has good anatomical and aesthetical outcomes,without postsurgical complications. Conclusions: Proposed method of surgical correction of lop ears is efficient, reduces surgical trauma and possible early and late postsurgical complications.

A190 Surgical approaches to the cranial base and the temporal region in cases of the tumors infiltrating the skull base M. Mazur*, T. Ryczer, A. Bruzgielewicz, R. Chmielewski, K. Niemczyk ENT Department, Warsaw Medical University, Warsaw, Poland Introduction: Tumors located in the temporal region and the nasopharynx usually develop fast. Symptoms occur in the advanced stage of the disease. Those tumors can infiltrate the surrounding tissues including the skull base and can rapidly cause serious damages. Aim: Evaluation of the available surgical approaches to the tumors of temporal region, nasopharynx and the skull base. Materials and methods: We present 3 case reports of patients with tumors of the temporal region and nasopharynx admitted to the ENT Department of the Medical University of Warsaw. In all cases different methods of surgical treatment were used. Results: In 39-year-old male with capsulated parotid tumor, the parotidectomy was performed. The zygomatic and temporal bones, temporomandibular joint and the external lamina of the cranial vault were removed because of the significant tumor infiltration. In 45-year-old male with the tumor located in temporal region and temporomandibular joint, modified Fisch approach and simple mastoidectomy were performed. The auditory ossicles, tympanic membrane, posterior and anterior wall of the external auditory canal as well as the lateral attic wall were removed. The tumor has grown into the pterygopalatine and infratemporal fossae. In 61year-old female with the nasopharyngeal tumor penetrating into the sphenoidal sinus, lateral rhinotomy was performed. The sphenoidal sinus was opened and the tumor was removed. Conclusions: Surgical techniques used in our patients varied depending on the region of the skull base involved and the extension of the tumor infiltration. Early diagnosis and surgical intervention are very important in case of the skull base tumor.

A191 Surgical management of parapharyngeal espace masses P. Martinez-Seijas*, N. Perez Martin, R. Lobato Perez, U. Bolinaga Zubizarreta, J. Arruti Gonza´lez Hospital Donostia San Sebastian, San Sebastian, Spain

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Objectives: We present two surgical techniques to remove parapharyngeal space masses. Materials and methods: Two cases of parapharyngeal space masses: One intraoral surgical access and another cervical access. The clinical radiological study, fine needle aspiration after imaging techniques (tumour vascularity). Discussion: The complex anatomy, the different pathological origins and different location site complicate the surgical masses removal without nerve and vascular lesions. Benign tumours predominate 80%. One fourth reports no symptons. Several approaches have been designed to facilitate removing the parapharyngeal space masses: the trasncervical approach is the most common, mandibulotomy in midline or Attia0 s access and intraoral access. Potential injury of the facial nerve a transcervical and transparotid access with facial nerve dissection is mandatory. Conclusion:

Conclusion: FNAC shows a rather high non-diagnostic rate. Nonetheless, FNAC shows a high sensitivity, specificity and overall accuracy in identifying malignant parotid disease. FNAC should therefore continue to form an important part of the preoperative assessment of all parotid swellings.

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J.G. (ID 28400), 75-years old female patient referred from another ENT Dept with 6-months history of painful swelling of both parotid glands (Fig.1, 2) with non-conclusive FNAB. Result: Benign lymphoepithelial lesion requiring differentiation with non-aggressive (smoldering) lymphoma. The clinical picture looked more like a chronic bilateral parotitis, so she was treated for 8 weeks with antinlammatory drugs (NSAIDs), with only partial improvement. The open biopsy was decided and final pathological report proved: Extra nodal marginal zone lymphoma; MALT; CD 20+ ; bcl+ ; CD43+/-; CD3-; Cyclin D1-; CD23-; EMA-; CD10- (Fig. 3, 4). Thereafter patient was transferred to the General Oncology Dept of Holly Cross Cancer Center to continue the treatment chemoimmunotherapy (Rituximab, CTX, VBL, Encorton). Conclusions: Benign lymphoepithelial lesion with signs and symptoms of chronic inflammation may be a mask of a Nonaggressive (smoldering) lymphoma. FNAB is not enough to exclude the transformation of Benign lymphoepithelial lesion to lymphoma.

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Patient comorbidities and preoperatory deficits influence the management. The tumor type, pathology also influence the management Key factors on tumour removal removal are: tumour vascularity, skull base involvent and facial nerve risk (transcervical and transparotid access) FNA after imaging techniques avoiding bleeding tumour.

A192 The accuracy of fine needle aspiration cytology (FNAC) in identifying malignant parotic swellings A. Canna2, A. Trinidade1, A. Al-Adhami2, M. Shakeel1*, A. Hussain1 1 Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, Aberdeen, UK; 2School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK Introduction: FNAC is in common use in investigating parotid gland swellings. It has been shown to be highly sensitive and specific in detecting parotid gland pathologies. Aim: To assess the reliability of FNAC in differentiating malignant from benign disease of parotid gland. Study design: Retrospective chart review. Ethics: Approved by institutional Clinical Effectiveness department. Method: Data were collected for patients undergoing parotidectomy between 1996 and 2007. For each patient, the FNAC diagnosis was compared with that made at histological examination. The latter was considered to be the ‘gold-standard’ comparator. Data was analysed using SPSS v16.0. Results: A total of 204 patients were identified, 175 (86%) patients underwent a preoperative FNAC. There was equal gender distribution with a mean age of 53 years (3.8–83.4). The FNAC smear was nondiagnostic in 30 swellings (17.1%). of the remaining 142 swellings, the histological evaluation revealed 4 (2.8%) ‘Benign non-neoplastic’, 126 (88.7%) ‘Benign neoplastic’ and 12 (8.5%) ‘Malignant’ lesions. The reliability of FNAC in identifying malignant disease showed a sensitivity of 83.3%, a specificity of 100%, negative predictive (NPV) and positive predictive (PPV) values of 98.5% and 100% respectively, with an overall accuracy of 98.6%. In 122 of 138 (88.4%) tumours (126 benign and 12 malignant) the exact tumour typing was correct.

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A193 The benign lymphoepithelial lesion of the parotid glands: diagnostic dilemmas (case report) M. Zawadzki* Holly Cross Cancer Centre, Kielce, Poland

A194 The case of a big neck arterio-venous malformation in young woman and the literature review R. Chmielewski, M. Kisiel*, E. Osuch-Wo´jcikiewicz, A. Bruzgielewicz ENT Department, Warsaw Medical University, Warsaw, Poland Vascular malformation (VMs) is an uncommon benign tumour of diverse location, of unknown etiology and pathogenesis. Usual presentation of the lesion is a round or oval, painless mass, compressing the surrounding tissues, of significant history before the first presentation. Most of those lesions arise in the head and neck area. Authors present a case of a 20-year-old female patient with arterio-venous malformation in the anterior triangle the neck. Growth of tumour caused significant accentuation of tissues on the left side of the neck. The tumour was successfully excised and histological examination revealed an arterio-venous malformation. The authors—according to the available literature—discuss the classification, clinical presentation, diagnosis and treatment of arterio-venous malformations. Current treatment options include observation, sclerotherapy, somnoplasty, laser reduction and surgical removal.

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A195 The case of a rare fronto-temporal region teratoma R. Chmielewski*, M. Kisiel*, R. Bartoszewicz* ENT Department, Warsaw Medical University, Warsaw, Poland Teratoma is a true neoplasm composed of an assemblage of tissue often allied to the site in which it arises. The components tend to be arranged in haphazard manner with asynchronous maturation of the involved tissue types. They grow independently of the host and can destroy adjacent tissue. Teratomas are most commonly located in the sacrococcygeal region, followed by the ovaries, testes, anterior mediastinum, retroperitoneum, and the head and neck area where are rare. Most of the cases in this area are diagnosed in the paediatric population. However an adult form does exist. We present the case of a 30-year-old male patient with tumour of the right fronto-temporal region. Growth of the tumour over a period of many years was painless and caused only an accentuation of the surrounding tissues. The tumour was excised and the histological examination revealed a teratoma. The authors—according to the available literature—discuss the classification, clinical presentation, diagnosis, and treatment of head and neck teratomas. While most of teratomas of the head and neck are benign, they can be malignant with regard to their location. It is important for diagnosis to be made promptly, usually with the aid of computerized tomography and biopsy. Treatment consists of conservative surgical removal which requires finesse and delicacy because of the close proximity to important anatomic structures of the head and neck region.

A196 The HPV infection or the p53 mutations? The role in the oral cancer development: preliminary report P. Golusinski* Great Poland Cancer Center, Poznan, Poland The majority of head and neck tumors harbor mutations affecting the p53 gene. Several studies have shown that tumors that seemingly harbor wild-type p53 may not have functional p53, as this protein is activated by binding of the human papilloma virus. This virus may be associated with the development of a subset of tumors arising in nonsmokers. Some studies indicate different outcome in patients with HPV induced oral cancer. The material constituted the DNA isolated from the frozen tumor tissue of the 50 oral cancer patients. p16INK4a immunohistochemistry with the use of CINtecTM Histology Kit was followed by the detection of high risk HPV (16, 18, 31, 33). This was performed by general primer GP51/61-PCR followed by reverse line blot genotyping. The mutations in 4–9 exons of p53 were first spot checked by screening with the SSCP technique and than sequenced. In the whole group none of the patients were HPV positive. The p53 mutations localized by SSCP were found in 10 cases and still need to be sequenced for determining type and location of mutation. The Polish population of HPV positive oral cancer patients may be relatively smaller than the one in the western Europe. The patients with mutations present in hot spots of p53 gene seem to constitute the major group within oral cancer patients.

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A197 The impact of comorbidity on the survival of patients with squamous cell carcinoma of the larynx V. Nesic1*, Z. Petrovic1, S. Sipetic1, S. Jesic1, D. Radaljac2, S. and ric1 1 Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre of Serbia, Belgrade, Serbia; 2ENT Department, Hospital ‘‘Dr. M. Marin’’, Loznica, Serbia Comorbid conditions are medical illness that acompany cancer. This study was performed to evaluate the impact of comorbidity, graded by the Adult Comorbidity Evaluation—27 index and the Charlson Comorbidity Index (CCI) on the disease-free interval and tumorspecific survival in patients undergoing curative treatment for laryngeal squamous cell carcinoma. Methods: The impact of comorbidity and other factors on survival was examined retrospectively in a cohort of 400 patients with squamous cell carcinoma who were admitted to our Institute from 2000 to 2003. Univariate and multivariate analysis with the use of life survival analysis techniques and logistic regression were performed. Results: Patients with either moderate or severe comorbidity had significantly worse 5-year survival than those with no or mild comorbidity (P \ 0.05). This study shows the higher comorbidity burden in supraglottic cancers in contrast to glottic tumors. This study also validates the composite comorbidity-TNM staging system and shows the composite system to be a better predictor of outcome than TNM staging system alone. Conclusions: Moderate and severe comorbidity have a greater and statistically significant impact on survival than the TNM staging system. The confounding effects of comorbidity should be considered in the TNM staging of laryngeal cancer to improve prognostic ability. Keywords: Laryngeal cancer, Squamous cell carcinoma, Comorbidity, Survival analysis, Outcome assessment.

A198 The impact of pinna preservation on early local relapse in radically resected T3/T4 carcinoma of the external auditory canal R. Dollner*, T. Osnes, G. Eigner Jablonski Department of Otorhinolaryngology, Head and Neck Surgery, Rikshospitalet, Universitetssykehus, Oslo, Norway Purpose: Although radical resection is mandatory in treating squamous cell carcinomas of the external auditory canal (EAC-SCC), there is a considerable debate about the need to remove the entire pinna during temporal bone resections. The present study focuses on the impact of pinna preservation in terms of early postoperative relapses. Materials: Between 1989 and 2008 a total number of 22 patients with EAC-SCC have been operated at our department with temporal bone resections (+/- parotidectomy and neck dissection). A subgroup of 17 cases has been staged as T3/4 according to the modified Pittsburgh classification. Their records were reviewed retrospectively with particular reference to surgical procedures, reconstruction, residual tumour (R) classification, adjuvant therapy and early relapse within 6 months following the operation. Two cases were judged ‘‘not

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resectbale’’ during the operation (R2) and were therefore excluded from the analysis. Further 6 cases were excluded because of i) microscopic residual tumour (R1), or ii) extended skin resections. For the remaining nine cases (all R0; 6 9 T3, 3 9 T4) the average follow-up time was 1.4 years. Results: In four out of nine cases the pinna was preserved during the temporal bone resection. During the first 6 postoperative months, relapses occurred in 2 out of these four cases (50%). In five cases the pinna was initially resected ‘‘en bloc’’, relapse occurred in one patient during the first 6 postoperative months (20%). Conclusion: In advanced EAC-SCC it seems advisable to remove the pinna regardless of the tumours histological lateral extent.

respectively. A radial forearm flap was used in one patient for reconstruction of the palate. Results: The surgical technique allows broad access to the nasopharynx on one side. Perfusion remained adequate for facial skin, the maxilla as well as adjacent mucosa. The facial scar was cosmetically well acceptable. One patient developed a small palatal fistula. Identification of the internal carotid artery proved to be difficult after previous dissection. Conclusion: The maxillary swing approach causes acceptable morbidity and cosmesis, while offering broad access to the nasopharynx on one side. Tumors with bilateral extension require an additional procedure to the other side.

A199 The long term impact of thyroidectomy in laryngeal cancer surgery

A201 The relationship between chronic otitis media induced hearing loss and the acquisition of social skills

H. Barrak* Medical College of Basra, Basrah, Iraq Introduction: Direct extension into the thyroid gland may occur in carcinomas of the larynx, trachea, esophagus and pharynx. The standard surgical treatment of these tumors usually includes partial or total thyroidectomy. The objective of our research work is to study excised thyroid lobes, trying to explain it is possible effect on the tumor prognosis and subsequent late complications. Materials and methods: Prospective study performed using a twenty serially sectioned whole organ laryngectomy with thyroidectomy specimens. The specimens were thoroughly sectioned at different level with particular attention to the thyroid lobes. The results were compared with the preoperative clinical data and the late postoperative complications. Results: Clinical tumor staging records were of advanced type. Two of the excised thyroid lobes demonstrated an invasion with squamous cell carcinomas. In most instances the subglottic space and the laryngeal skeleton were involved by tumor cells. Seven patients developed stoma recurrence and three had recurrent pharyngeocutaneous fistula. Conclusion: Thyroidectomy is not a routine part of total laryngectomy and had questionable efficacy to the late patients’ outcome and tumor recurrence. While metastasis to the subglottic site accused as a poor prognostic sign of laryngeal carcinoma.

A200 The maxillary swing approach for malignant tumors of the nasopharynx P. Federspil*, C. Simon, K. Zaoui, P. Plinkert University Hospital Heidelberg, Heidelberg, Germany Background: Malignant tumors of the nasopharynx are difficult to be approached surgically. William Wei described the maxillary swing procedure as an anterior approach. Materials and methods: The maxillary swing approach was used in two patients with HNSCC of the nasopharynx. Both patients had recurrent tumor after primary surgery and chemoradiation,

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S. Bidadi*, M. Nejadkazem, M. Naderpour Tabriz University of Medical Sciences, Tabriz, Iran Objective: To investigate the effects of hearing loss caused by Chronic Otitis Media (COM) on acquiring social skills. Subjects and methods: A case–control study of 90 patients, including patients with COM, age range 15–30 years, was conducted in the Otorhinolaringology ward of Tabriz University Hospital. Social skills were assessed using a social skills questionnaire. Results: Social skill score were found to be lower in hearing impaired COM patients compared to the control group (P \ 0.001). Social skill disabilities in patients with bilateral COM were more severe than patients with unilateral COM and the controls (P \ 0.001). Correlation between social skills score and degree of hearing loss was significantly negative (P = 0.014, rho = -0.314). This data indicates an inverse relationship between hearing loss and social skills. Conclusion: Social skills and educational level of COM patients are affected due to hearing impairment. This study suggests that chronic otitis media has effects on social development and education.

A202 The relationship between chronic otitis media-induced hearing loss and occupation S. Bidadi*, M. Nejadkazem* Tabriz University of Medical Sciences, Tabriz, Iran Objective: To investigate the effects of hearing loss caused by chronic otitis media (COM) on occupation. Subjects and methods: A case–control study of 90 patients, including patients with COM, age range 15–30 years, was conducted in the otorhinolaryngology ward of Tabriz University Hospital. Employment status was evaluated for each group. Results: Jobless and House wife cases were found to be higher in COM patients with bilateral hearing impairment compared with the unilateral COM group (P \ 0.001).

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Conclusion: Occupation is influenced by hearing impairment of patients with the history of COM, following its influence on social skills and educational level.

A203 The treatment of the children suffering from frequent long lasting catarrhal diseases T. Dyachenko* Private Practice, Lugansk, Ukraine In the last decade has been growing the quantity of the children suffering from long lasting catarrhal diseases, i.e. children have been sick more then 4 times during the last year for 10–14 days. After examination it was found that they are having combination of rhino laryngological pathology (chronically compensated tonsillitis, chronically faryngitis, long lasting adenoiditis, ethmoiditis) with allergy, disbiosis and gastrointestinal disturbances. The peculiarity of these children is that after regular episode of exacerbation after 2–3 weeks occurs recurrence. This state we connect with genetic predisposition (parents in the childhood were suffering from same diseases), ecological factors (ecology of nutrition and environment), diet violation, irrational using of medicines, carrying of mixed flora. We use such scheme of treatment: 1. Sanation of nidus: adenectomia (usually low effective), irrigation of lacunas of tonsils with antibacterial remedies using bacteria sensitivity. 2. In the mucosa of pharynx in the back wall we make injections using scheme: Lymphomyosot, Traumeel S, Belladonna hommacord ‘Heel’ Baden-Baden. 3. Correction of flora: pro- and prebiotics, antibacterial remedies. 4. Shortening of entry of allergens. 5. Diet (large quantity of ballast substances, exception of toxically substances—conservants). 6. Physiotherapy and intensive respiratory gymnastics (by Strelnikova). 7. Psychotherapy. Therapy is individual, peculiarity is long lasting treatment, observation, but maximally sparing of psychics.

A204 The usefulness of preoperative computed tomography diagnosis of nonrecurrent inferiorlaryngeal nerve Y. Wang*, Q. Ji, D. Li, C. Huang, Y. Zhu, Q. Shen, T. Sun, L. Zhang Cancer Hospital, Fudan University, Shanghai, Japan Objective: The non-recurrent inferior laryngeal nerve (NRILN) is a nerve anomaly that is associated with arterial abnormalities (absence of the brachiocephalic trunk and aberrant subclavian artery). The purpose of this study was to assess the possibility of diagnosis of an aberrant subclavian artery by computed tomography (CT) of the neck, which might help preoperative recognition of the NRILN and prevention of intraoperative nerve damage. Methods: An NRILN was identified intraoperatively in 8 thyroid surgery patients treated in our hospital between January 2005 and August 2008. We retrospectively studied the preoperative CT films from these patients. We evaluated the positional relationship between the right subclavian artery and the tracheoesophagus, and also

1093 evaluated the relationship between the right subclavian artery and the common carotid artery. Results: The right subclavian artery was detected on the dorsal side in all 8 NRILN cases. The relationship between right common carotid artery and subclavian artery was distant in all cases. Absence of the brachiocephalic trunk and existence of aberrant subclavian artery were verified in on case (Case 4) by magnetic resonance angiography (MRA). Conclusions: It was possible to predict an aberrant subclavian artery by identifying the position of the right subclavian artery on the CT film of the neck. When an anomaly of the subclavian artery is thus preoperatively detected, NRILN can be preoperatively predicted, which likely will enable prevention of vocal cord paralysis. Keywords: Non-recurrent inferior laryngeal nerve, Aberrant subclavian artery, Common carotid artery, CT, MRA, Preoperative diagnosis.

A205 Thornwaldt cyst: a case report E. Theos, V. Lachanas*, C. Evaggelopoulos, C. Gantas, P. Pavlidis, C. Makrypides, E. Gkletsou, T. Apostolidis, C. Kourtopoulos Otorhinolaryngology, Head and Neck Surgery Department, School of Medicine, University of Thessaly, Larissa, Greece Thornwaldt’s cyst is an uncommon type of nasopharyngeal cyst that develops as a result of abnormal embryologic development at the posterior wall of the nasopharynx. They are usually asymptomatic, but may cause clinically significant nasal symptoms. We present a case of 37 years old man who complained of nasal obstruction and persistent post-nasal drip. Clinical examination revealed a smooth nasopharyngeal mass, which was completely obstructing the right and 70% of the left nasal choanae. CT and MRI scans revealed a smooth cystic mass, which did not invade the surrounding structures. Under general anesthesia the patient underwent transoral marsupialization of the cyst. Histopathological examination set the diagnosis of Thornwaldt’s cyst. Three months postoperatively the patient is free of symptoms while no recurrence occurred. Thornwaldt’s cyst should he remembered as an uncommon but potentially treatable cause of symptoms seen in a typical otorhinolaryngology practice. Etiology, clinical manifestations, imaging findings, differential diagnosis and treatment are reviewed.

A206 Total laryngectomy and neck dissection: prognostic significance of positive lymph nodes A. Antoniadis*, D. Rachovitsas, A. Nikolaou, S. Triaridis, G. Tsiropoulos, V. Vital ENT Department, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece Introduction: Laryngeal carcinoma accounts for approximately 40% of carcinomas of the head and neck. Advanced-stage cancer (III and IV) is usually treated by total laryngectomy (T/L) and neck dissection (N/D), followed or not by radiation and chemotherapy. Patients and methods: Patients of the University ENT Clinic of Thessaloniki, in AHEPA Hospital, that were treated for laryngeal cancer by T/L and N/D the last 5 years (from 1 January 2004 to

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1094 December 2008), were divided in two groups, according to the histologic confirmation of lymph node metastases. The groups are compared with each other for recurrence ratio. Results: 238 patients were diagnosed with carcinoma of the larynx during the last 5 years. Most of them were males (95%) and the mean age was 63 years (range 38–89). The most common histological type was SCC (211 of 238), while 137 patients (58.8%) had cancer of the glottis, followed by suppraglottic (37.5%), transglottic (3.3%) and rarely subglottic (\1%) cancer. 90 of the above patients were treated by T/L with concurrent N/D (selective or radical). Histological results were positive for lymph node metastases in 37 of them, while 53 were free of metastases. Recurrence rate was 29.7% (11/37 patients, all with post-surgery radiation) and 26.4%(14/53, 7 of them with postsurgery radiation) respectively. Conclusion: It is important to notice that the recurrence ratio of patients with or without metastases to the lymph nodes doesn’t seem to differ significantly.

A207 Total laryngectomy: functional and oncologic results D. Milisavljevic* University ORL Hospital Nis, Nis, Serbia Aim: The aim of our study is to update our experience with total laryngectomy and to review the functional and oncologic results of operation. Materials and methods: In the period of January 1998 to January 2008, 168 patients were underwent to total laryngectomy and neck dissection at the University ORL Clinic Nis, Serbia. Results: In our group of operated patients all our patients accepted to be operated after thoroughly explained possibilities of their treatment. They would rather have all their cancer removed and they preferred surgery and radiation therapy, understanding that their ability to communicate would be significantly affected. The closure of hypopharyngeal defect we did with an interrupted suture of 3-0 silk, with knots tied on the inside. The immediate postoperative hemorrhage were noticed in 7 our patients and in 5 cases was due to dislodgment of a ligature and in 2 patients of an unligated vessel but all required immediate exploration of the wound, removal of the clot and ligation of the bleeding vessel. In 17 patients developed pharyngocutaneous fistula. Conclusion: Total laryngectomy is the last resort in the management of laryngeal cancer, not in the sense that it should be employed after other modalities or operative procedure have failed, but rather in the sense that it should be employed only when it is the procedure that it will produce the best chance of cure for a specific case (Alfio Ferlito).

A208 Transoral removal of the large parapharyngeal neurofibroma using the harmonic scalpel: a case report M. Marjanovic Kavanagh1*, Z. Sabol2, S. Janjanin1, D. Prgomet1 1 KBC Zagreb, Zagreb, Croatia; 2Private Policlinic Sabol We report a case of a 19-year-old male patient with a neurofibromatosis type 1, who had a parapharyngeal and intraspinal

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 neurofibromas. To our knowledge this is the first report of a transoral removal of a huge parapharyngeal space nerofibroma using a harmonic scalpel. The patient suffered from odinophagia and left sided hemiparesis. All over the body there were multiple cafe´ au lait spots and numerous subcutaneous and cutaneous neurofibromas. The MRI showed a 6 cm big tumor in the left parapharyngeal space and a big intradural neurofibroma (C3–C4). After neurosurgical treatment the parapharyngeal tumor was successfully removed. Histological examination revealed a neurofibroma. The tumor showed no recurrence in a 3 months follow-up period.

A209 Transoral robotic surgery (TORS) in laryngeal and hypopharyngeal cancer S. Kim*, Y. Park, E. Choi Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea Objectives: The current trend in managing laryngeal and hypopharyngeal cancer is to perform organ preservation therapy which improves quality of life and decreases treatment related morbidity. Transoral robotic surgery (TORS) can overcome the limit of ‘line of sight’ often met in classic transoral procedure. We utilized robotic surgical system to evaluate the feasibility and oncologic safety of transoral partial pharyngectomy and laryngectomy. Methods: TORS was performed using ‘da Vinci Surgical Robot’. FK retractor was used to expose the cancerous lesion transorally, and an endoscopic arm was introduced through the oral cavity with two instrument arms placed 30 degrees apart from the endoscopic arm. We performed TORS on one patient with pyriform sinus carcinoma and 4 patients with glottic carcinoma, as a prospective human trial. Results: Average surgical time measured was 39 min, including average of 25 min used for locating the robotic surgical system in place and exposing the lesion. Transoral robotic surgery (TORS) can provide magnified three dimensional view and overcome the limitation resulting from the ‘line of sight’ which hinders classic transoral procedure. All surgical resection margins were free of carcinoma. There were no perioperative complications, and also no mortality due to the surgical procedure. Conclusions: This study demonstrates that the application of TORS for partial pharyngectomy and partial laryngectomy is technically feasible and safe. Keywords: da Vinci Surgical Robot, Transoral robotic surgery, Glottic cancer, Hypopharyngeal cancer.

A210 Traumatic pseudoaneurysm of the left distal external carotid artery presented as a parotid mass and facial nerve palsy E. Rioja Pen˜aranda*, B. Martı´nez Vidal*, A. Obando Valverde*, A. Bore´s Dome`nech, M. Rusiecka, F. Marin˜o Sa´nchez, F. Sabater Mata de la Barata, M. Bernal Sprekelsen Servicio de Otorrinolaringologı´a, Hospital Clı`nic, Barcelona, Spain

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Introduction: A pseudoaneurism presenting as a parotid mass is a rare complication after trauma. External carotid pseudoaneurisms have been reported in literature but few reports have been found involving the distal external carotid artery. Some authors consider that the treatment of external carotid pseudoaneurisms is surgical excision. We present a case that was treated successfully with local embolization. Case report: A 65-year-old man who arrived to the emergency room with a 3 mm stab wound localized in the left outer external ear canal immediately after the tragus. Otoscopy and physical examination was normal. 3 weeks later he returned with a left parotid pulsatile mass and a House-Brackman V facial nerve palsy. Angiography demonstrated a pseudoanerysm of the external carotid artery before the exit of the maxilar and temporal branches, which was successfully embolized. 1 week later there was no parotid mass and facial palsy was recovered before 12 weeks. Conclusion: Parotid masses represent 3 to 6% of all head and neck tumors. Pseudoaneurysms are very rare in this region and should be highly suspected after a history of trauma. We suggest that embolization can be a useful treatment for distal external carotid pseudoaneurysms.

A211 Ultrasound scan +/2 fine-needle aspiration cytology assessment of neck lymphadenopathy in head and neck squamous cell carcinoma N. Dulguerov1*, H. Young1, P. Norris2, T. Beale1, S. Morley1, N. Kalavrezos1 1 University College Hospital; 2Queen Victoria Hospital, London, UK USS +/- FNAC has become an important tool to assess the presence of neck metastasis in head and neck squamous cell carcinoma (HNSCC). Neck lymphadenopathy is of paramount importance for the overall outcome, whilst the management of the neck depends on the presence of neck metastasis. We examined if USS +/- FNAC can accurately predict the presence of neck metastasis in head and neck SCC. All patients diagnosed with HNSCC in our institution between 2005 and 2008 were submitted to preoperative USS +/- FNAC. The patient population in our study included the sub-group of patients who were treated with neck dissection. The results of 111 neck dissections showed an USS sensitivity of 90%, specificity of 59% and a negative predictive value of 75.9%. The inclusion of ultrasound guided fine needle aspiration cytology raised the sensitivity to 93%. As far as the localisation of the neck lymphadenopathy when neck disease was present, the radiologist was able to correctly identify the level of the metastasis in 83.6%. In conclusion, we demonstrated that USS +/- FNAC is a reliable tool to confirm the presence of neck disease. Nevertheless, future prospective study should confirm its additional reliability and accuracy especially in the management of the clinically N0 neck.

A212 Unusual malignant laryngeal neoplasms S. Ouzounidou*, G. Tsiropoulos, E. Beis*, K. Markou, V. Vital ENT Department, AHEPA University Hospital, Thessaloniki, Greece

1095 Introduction: Malignancies of non-squamous cell origin constitute only a small fraction of malignant laryngeal neoplasms, with controversial management strategies and variable prognosis. This diverse group of diseases may comprise tumours of epithelial, neuroectodermal and mesodermal origin. Aim: The study is aimed at presenting cases of special oncological interest due to their rarity. Materials and methods: We retrospectively reviewed the files of patients who were investigated and treated for non-squamous cell laryngeal malignancies in the Department of Otolaryngology, Head and Neck Surgery of AHEPA University Hospital between 1992 and 2008. Results: of 1,270 patients who attended the Head and Neck Unit for laryngeal tumours, 16 individuals were diagnosed with and treated for malignancies of non-squamous cell origin (1.26%), namely 6 sarcomas, 4 neuroendocrine tumours, 3 spindle cell carcinomas and single cases of adenocarcinoma, adenoid cystic carcinoma and nonHodgkin’s lymphoma. All patients were males with a mean age of 56.8 years at presentation. Treatment strategies included surgery, radiotherapy and chemotherapy, either as single modalities or as combinations according to individual based indications. The followup period ranged from 15 days to 239 months. We were unable to obtain up-to-date information about survival in 6 cases, as these patients were lost at follow-up. of the remaining 10 patients, 4 died of their disease. The remainders were free of disease at the time of our recent data update. Conclusion: Malignancies of non-squamous cell origin comprise a heterogeneous group of tumours, which very rarely affect the larynx. Treatment and prognosis vary between subtypes.

A213 Use of antlerogenic mesenchymal stem cells in reconstruction of auricular cartilage: preliminary studies on animals M. Zatonski1*, M. Cegielski2, W. Dziewiszek3, M. Bochnia1 1 Department of Otolaryngology, Faculty of Dentistry, Medical University of Wroclaw, Wrocław, Poland; 2 Department of Histology and Embryology, Medical University of Wroclaw, Wrocław, Poland; 3Department of Pharmacology, Medical University of Wroclaw, Wrocław, Poland The search for the ideal material suitable for auricular cartilage reconstruction continues for over 100 years. Different materials and methods were introduced up date, including implantation autogenic and allogenic cartilages, high-density polyethylene frameworks or synthetic biocompatibile, biodegradable, porous polymers impregnated with insulated autogenic chondrocytes. None of available methods proved to be ideal. We have made an attempt to use antlerogenic mesenchymal stem cells (AC) to reconstruct auricular cartilage of rabbits’ ears. Implant scaffolding consisted of Spongostan (believed to be the best available material for cell implantation) saturated with suspension of AC. Survival and regeneration abilities of xenogenous cells were determined by histologic, immunohistochemical, and electron microscopy analysis of the grafts. In each case, healing occurred properly and neither local inflammation, necrosis nor implant rejection was observed. In every case, the hyaline cartilage lesion was replaced by new fibrous cartilage. Host’s immune response was very weak although we did not introduce any

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1096 immunosuppression. Implanted AC were not rejected and possibly took part in the reconstruction of missing sections of the scaffolding of the rabbits’ ear cartilages. Low immunogenicity of AC, simplicity, efficiency, and low costs of production of implant material are the benefits of this method. Further research should answer the question whether AC are the long-sought-after ideal material for the reconstruction of cartilaginous tissue lesions in various species, including human.

A214 Usefulness of cephalometric measurements in obstructive sleep apnea patients E. Olszewska1*, A. Sieskiewicz1, E. Tarasow2, M. Rogowski1, J. Rozycki2 1 Department of Otolaryngology, Medical University, 2 Department of Radiology, Bialystok, Poland Obstructive sleep apnea syndrome (OSAS) is characterized by repeated narrowing or even upper airway collapse while breathing during sleep. The pathophysiology of OSAS is related with local anatomical predispositions to OSAS. The aim of the study was to describe the use of cephalometric craniofacial computed tomography in OSAS patients. Materials and methods: Thirty-four randomly selected patients with snoring and sleep-disordered breathing were included in this study. A control group included 30 patients. These patients had no snoring or clinical evidence of sleep—disordered breathing evaluated by polysomnographic test. All patients had polysomnography and craniofacial CT scans. Results: Cephalometric measurements in OSAS group were significantly different compared with that in the control group. Statistically different mean values between OSAS patients and the control groups were found for all parameters except ANS-PNS, angle ANS, UL, PNS-A, Go-TB, TT-ET and angle N-S-H in CT measurements. Conclusion: Obstructive sleep apnea syndrome is associated with statistically significant changes in cephalometric measurements. Craniofacial CT adds further information regarding the anatomical assessment of patients with OSAS. It is an easy and accurate method. Cephalometric evaluation may serve as an useful diagnostic tool for qualification for surgical procedure. Further studies will be conducted to enlarge the study group and to evaluate the efficacy of surgical procedures according cephalometric analysis in patients with sleep disordered breathing.

A215 Utility of CT lymphography in sentinel lymph node detection with tongue cancer K. Honda*, S. Suzuki, W. Wong, T. Saito, K. Ishikawa Deaprtment of Otorhinolaryngology and Head and Neck Surgery, School of Medicine, Akita University, Akita, Japan Purpose: Though the blue dye method or radioisotopic method have been generally used to detect the sentinel lymph node (SLN), it has been pointed out that the lymphatic mapping cannot be obtained

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 preoperatively with the blue dye method and that SLN mapping with radiotracers is difficult when the SLN is close to the injection site because of shine-through radioactivity. In this study, we examined the utility of the technique of detecting SLN with CT lymphography in patients with tongue cancer. Materials and methods: 11 patients with T1, T2N0 tongue cancer were studied. Total 2 ml iopamidol was injected into the peritumoral region followed by obtaining CT images at 1, 3, and 5 min after injection, and identification and marking of the sentinel lymph node were performed on the day before the operation. The pathohistological examination of the SLN was performed by frozen sections. On the negative metastasis of the SLN, neck dissection was not performed to the T1N0 case. Pull through primary tumor removal with selective neck dissection (Level I–III) was performed to the T2N0 case regardless of the presence of the metastasis of the SLN. Result: The SLN was able to be identified excluding one case. The metastasis of the SLN was found with one case of T2N0 and one case of T1N0. Conclusion: CT lymphography in SLN detection with tongue cancer is quite useful because the anatomical relation between tumor, lymph-vessels, and SLN was recognized before operation.

A216 Verrucous carcinoma of the head and neck C. Yeo*, D. Kim*, J. Lee* Department of Otolaryngology, Dong San Medical School, Keimyung UniversityTaegu, South Korea Background and objectives: Verrucous carcinoma is a well- differentiated squamous cell carcinoma with minimal cytologic atypia. Although usually curable at an early stage, it can be locally aggressive if left untreated. This study provides the clinical features and treatment outcome of verrucous carcinoma of the head and neck. Materials and methods: From 1991 through 2001, 10 patients received initial treatment for verrucous carcinoma of the head and neck at Keimyung university Dong-san hospital. We retrospectively reviewed the presentation, diagnosis, treatment and outcomes in these patients. All cases were confirmed by histologic examination. Results: All but two patients were men, and most were smokers. Tumors originated most frequently in the oral cavity(50%) and larynx (30%). The TNM classification (AJCC 2002) was T1 in 5 patients, T2 in 3 and T3 in 2. Eight patients were treated by surgical excision alone and one patient was treated by radiation after surgery. Local recurrence without neck involvement occurred in 2 of the 10 patients. The overall cumulative survival rate was 100%. Conclusion: When discovered early, verrucous carcinoma of the head and neck can be treated effectively with wide local excision with good results, it is different from classic squamous cell carcinoma.

A217 Vestibular stem cells: pluripotency and differentiation potential D. Vintila*, O. Gavriliuc, G. Iovanescu, V. Paunescu, C. Tatu University of Medicine and Pharmacy V. Babes Timisoara, Timisoara, Romania

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Introduction: The purpose of the ongoing research is to improve our current skills and knowledge in stem cell isolation, cultivation and differentiation from the utricular and saccular epithelia of young mice. Materials and methods: We harvested utricles and sacculi from 7 days old NMRI mice. Utricles were trypsinized in order to isolate single cells. Obtained cells were cultivated at 37C and 5% CO2 in DMEM with F12 Nutrient mixture, B27, N2 supplement, IGF-1 and EGF. Sphere pluripotency was established with the help of stem cell markers Nanog and Oct-4. We mechanically dissociated primary spheres and cultivated them in the culture media mentioned above. Secondary spheres were placed on fibronectin coated tissue culture slide chambers in the absence of IGF-1 and EGF in order to observe their subsequent proliferation and differentiation. Cells were characterized by immunofluorescence and immunohistochemistry for myosin VIIA (hair cell marker) and nestin (intermediate filament VI marker). Results: We proved that vestibular epithelia contains pluripotent stem cells which were able to form cell clusters called spheres. Sphere-derived cells’ pluripotency was demonstrated by the expression of nanog, oct 4 and nestin markers (cell progenitors). Also sphere dissociation and separate cultivation of the isolated cells lead to the formation of larger spheres and in higher amounts compared to the original spheres, proving that these cells are not only pluripotent but also capable of self-renewal. Single spheres harvested and cultivated on fibronectin gave rise through differentiation to different cell types including neuron like-cells which were positive for myosin VIIA and nestin.

A218 What are psychogenic disorders in otorhinolaryngology? M. Astrid* Psychotherapy Practice, Leverkusen, Germany Introduction: Due to the diversity of the relevant diseases, the classification of psychogenic disorders in the field of otorhinolaryngology is difficult in terms of differential diagnosis. In this context the term ‘‘psychogenic’’ should in general not be equated with ‘‘psychosomatic’’. We have drawn up a nosological catalogue of psychogenic disorders in the field of otorhinolaryngology. Method: Based on the 2008 version of the World Health Organisation’s International Classification of Mental and Behavioural Disorders [ICD 10 Chapter V(F)], we classified the various psychogenic disorders in the area of otorhinolaryngology into four nosological groups. Results: The first group of diseases covers multifactorial diseases of a physical nature influenced by mental factors. These are psychosomatic disorders in the actual (original) sense. Here there is a pathological, organic correlative and a mental trigger. Examples include facial rosacea and orofacial pain syndrome. The second group lists purely psychological otorhinolaryngological diseases, for example psychogenic hearing and speech disorders and psychogenic globus pharyngeus. The third group covers the traumatic disorders, i.e. mental disorders arising through difficulty in handling the consequences of severe physical or emotional trauma. These include violence and stigmatisation from accidents or tumour destruction. The fourth group covers reactive disorders. These are characterised by somatic and/or emotional symptoms in cases of psychosocial stress and chronic overload. The complex symptoms caused by psychosocial stress through progressive deafness are representative of this.

1097 Conclusion: This nosological classifications facilitates the differential diagnostic assessment of psychogenic disturbances in the field of otorhinolaryngology. LARYNGOLOGY

A219 Acquired subglottic stenosis in a 1 year old infant: restoration by cricotracheal reconstruction N. Argyriou*, S. Gougousis, A. Skouras, G. Kontzoglou ENT Department, Hippokratio General Hospital, Thessaloniki, Greece Introduction: Subglottic stenosis can be congenital or acquired. Main cause of acquired subglottic stenosis is long term intubation, like in the presented case. Main symptoms include stridor and shortness of breath. Due to the severeness of the above symptoms, tracheostomy is frequently needed. Laryngotracheal and cricotracheal reconstruction are consist the main therapy of acquired and congenital subglottic stenosis. Material: A 2 months old infant was admitted in intensive care unit after a cardiosurgical operation, and he stayed intubated for 7 days. Extubation was unsuccessful, and an endoscopy was performed, which showed an acquired subglottic type III Cotton stenosis, and forced us to proceed in tracheostomy. Reconstruction of the stenosis was decided to take place in a second term. Methods: One year after tracheostomy, a cricotracheal reconstruction had been performed by segment resection with an end to end anastomosis. A line of sessions followed up, where the existing granulomas were removed, and the lumen was dilatated by stents of increasing diameter. 6 months after reconstruction, the subglottic area was free of granulomas, the lumen of larynx and trachea was satisfactory, and patient¢s breathing was normal. Discussion: Due to long term intubation in intensive care units, the frequency of subglottic stenosis has been increased. Cricotracheal reconstruction is a method that can restore such kind of abnormalities.

A220 Acute external laryngeal trauma: a case report D. Radaljac1*, Z. Petrovic2*, V. Nesic2*, T. Radaljac1* 1 ENT Department,Hospital Dr M.Marin, Loznica, Serbia; 2 Institute of Otorhinolaryngology and Maxillofacial Surgery, CCS, Belgrade, Serbia Objectives: Acute external laryngotracheal trauma comprises less than 1% of all trauma cases seen at major centers. Management begins with an assessment of the mechanism of injury, the level of injury, and the severity of injury. Several authors have proposed management protocols, but many controversies remain. Despite those controversies the ultimate goal is universally accepted, to safely and atraumatically establish a secure airway. Methods and results: We presented a case (man 55 years old) of severe laryngeal injury caused by blunt trauma to the neck. Patient had symptoms of stridor, dyspnea, dysphagia, odynophagia, dysphonia. Laryngological examination revealed a massive hematoma and edema of hypopharynx and larynx. Patient’s condition was unstable, but he

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1098 refused any surgical management to establish a secure airway, despite our recommendations. CT was employed and it revealed massive, nonhomogenic formation of hypopharynx, larynx, sublotis, prevertebral space and along m.longus coli. Systemic corticosteroids were administered, antibiotics and proton pump inhibitor were also included. The result of the treatment was good airway function and good voice. Conclusions: Early recognition, accurate evaluation and proper treatment will not only prevent significant morbidity and mortality, but will greatly improve the patient’s clinical outcome.

A221 Airway reconstruction and cricotracheal resection: lessons learned M. Wolf1,2*, A. Primov-Fever1 1 Department of Otorhinolaryngolgoy Head Neck Surgery, The Sheba Medical Center, Tel-Hashomer, Israel; 2Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel Background: Intubation and tracheostomy are the most common causes for benign acquired airway stenosis. Objectives: To discuss problems encountered along the course of practicing airway reconstruction. Methods: A review of all patients who underwent cricotracheal resection between 1995 and 2008. Results: The study included 96 patients (31 women and 65 men) aged 15 to 81. 72 patients suffered from complete (31) or near total (41) obstruction. Concomitant lesions included impaired vocal cord mobility (16), tracheo-esophageal fistula (10) and distal tracheal malacia (3). Crico-tracheal anastomosis was performed in 64, thyrotracheal in 15 and tracheo-tracheal in 17 patients. Staged procedure was planned for quadriplegics, bilateral vocal cord paralysis and very severe COPD patients. Suprahyoid release was performed uneventfully in nearly half of patients. Restenosis, occurred in 16 patients, was addressed by T-tube insertion (8), dilatations (2), tracheal stent for distal malacia (1), revision surgery (1) and tracheostomy due to aspirations (1). Decanulation was eventually achieved in 88 patients (91.6%). Early and late complications occurred in 31 patients, the most common being subcutaneous emphysema (6). One patient died of acute myocardial infarction on the 14th post-operative day. Nine successfully operated patients were re-intubated in the first year of follow up due to severe heart and pulmonary diseases. Conclusions: CTR shares a relatively high rate of success also in revised procedures. The complexity of patient’s medical status addresses questions in relation to the possibility of single or staged procedures, the goal and extent of surgery and the criteria of defining operative success.

A222 Anticoagulation and spontaneous cervical hematoma M. Cardoso*, F. Vales, M. Santos Hospital De Sa˜o Joa˜o EPE, Porto, Portugal Background: Cervical hematoma is a rare entity that can progress rapidly to airway obstruction. Associated conditions include coagulopathic states, trauma, infection, and foreign body ingestion. Here we describe a case of a cervical hematoma associated with anticoagulation therapy.

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Methods: A case report is presented and the literature reviewed. Results: A 45-year-old woman treated with warfarin for protein C resistance and multiple ischemic events presented to the emergency department with progressive dysphonia, dysphagia and dyspnea. Laboratory values showed significant increase of international normalized ratio (INR). Fiberoptic laryngoscopy revealed an hematoma extending to the larynx and left pharyngeal wall with glottic lumen reduction. Computed tomography scan (CT) of the neck revealed a laryngeal and pharyngeal hematoma. Fresh frozen plasma and vitamin K were used to revert the coagulopathy. The patient remained in observation in an intensive care unit, with a favorable progression and no need to intubation. Conclusion: Cervical hematoma with pharyngeal and laryngeal involvement can lead to airway obstruction and be fatal. The authors present a case of a spontaneous cervical hematoma associated with anticoagulation therapy and discuss the management of this entity. The literature is reviewed.

A223 Application of the low intensity laser radiation in the supraesophageal reflux E. Osipenko*, N. Dergavina Federal Research Clinical Centre of Otorhinolaryngology, The Ministry of Public Health, The Russian Federation, Moscow, Russia The purpose of our work was to find out the prevalence of laryngopharyngeal reflux (LR) disease among the representatives of vocal professions, to define the influence of this pathology on their professional activity and also to estimate the efficiency of the application of the lowfrequency laser radiation in the complex treatment of the patients. Methods: We have examined 86 patients engaged in academic and folk singers for more than 3 years (24-h pH - monitoring, of the device « Gastroscan-24 » , equipped with larynx sensor and allowing to fix the reflux episodes at the larynx–pharynx level, voice acoustic analysis, videostrobolaryngoscopy). The patients have been divided into two groups: I group (n = 39) was treated with the use of antireflux treatment, II (n = 47) in addition to the mentioned therapy were treated with the use of physiotherapy, consisting of the influence by low intensity laser radiation. We have used the device ‘Orion 5’ equipped with the flexible larynx attachment as the source of laser radiation. As a result of our examination we have noticed that there were less complaints among the patients of the second group and there was the improvement in laryngoscopy and the indices of the voice acoustic analysis can be achieved quicker than among patients of the first group. Conclusion: 1. The received data allow us to come to conclusion that the presence of LR among the singers has bad influence on labour activity. 2. The application of the low intensity laser radiation in complex treatment allows increasing its efficiency.

A224 Basics of laryngostroboscopy M. Rainer* Department of ENT, University Hospital, Dresden, Germany

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 The basics of laryngostroboscopy are conveyed in a course of 1 h. The principles of this method, the conditions of examination, evaluation criteria for the vibration characteristics of the vocal folds and the use of this basic laryngological and phoniatric examination technique will be illustrated. Typical findings will be presented using video recordings from phoniatric consultations. By the use of onsite sets there will be the opportunity in a hands-on fashion to practise and experience this examination technique. The course is designed to encourage to use stroboscopy in a daily routine and refresh basic knowledge.

A225 Bilateral vocal cord palsy associated with laryngeal myxedema V. Kova´cs1*, J. Werner2, A. Teymoortash2, G. Lichtenberger1 1 Department of ORL-HNS, Ministry of Defence-State Health Centre, Podmaniczky u. 109-111., 1062 Budapest, Hungary; 2Department of ORL-HNS, Philipps-University, Biegenstraße 10, 35032 Marburg, Germany Objective: Bilateral vocal cord paralysis and laryngeal myxedema are sever complications of thyreoidectomy. Management of dyspnoea caused by association of these complications means a great therapeutic challenge. Methods: In the acute post-operative period of thyreoidectomy for managing dyspnoea caused by bilateral vocal cord palsy we perform reversible endoscopic vocal cord lateralisation. However later when there is no chance for recovery of the recurrent laryngeal nerves irreversible procedure is done. Applying these operative techniques we can achieve satisfactory breathing in about 95% of cases avoiding tracheostomy. In 5% of cases there are other comorbidities in the background of unsuccessful operative results. From these factors we emphasize the role of myxedema. Between 01 January 1989 and 30 November 2008 we performed 161 reversible and 135 irreversible vocal cord lateralisations. From these cases 4 patients had further obstruction due to myxedema. We demonstrate our experience achived by managing these patients. Results: Applying endoscopic glottis dilating operations and levothyroxine replacement therapy sufficiently wide glottic chink has been achieved in all the cases. Conclusion: According to our experience dyspnoea caused by bilateral vocal cord palsy after thyreoidectomy needs complex interdisciplinar therapeutic approach beside glottis dilating operations.

A226 Bilateral vocal cord paralysis in von Recklinghausen’s neurofibromatosis type 1 M. Cisternas Bittencourt*, E. De la O Corrochano, G. Fernandez Rodriguez, M. Garcı´a Jimenez, M. Lavilla Martin de Valmaseda, F. Ramos Puerto, J. Marcos Calle Department of Otorhinolaryngology, Head and Neck, Hospital San Pedro de Alcantara, Ca´ceres, Spain

1099 Introduction: Von Recklinghausen’s neurofibromatosis is an autosomal dominant inherited neurocutaneous disorder. It has two major subtypes NF-1 and NF-2 and a third variant known as segmental type. NF-1 is the more common subtype, affecting 1 in 4,000 people in the world. NF-1 is characterized by developmental changes in the nervous system, skin, bones, and other tissues, with the development of neurofibromas in the brain and spinal cord. Method: A case of a patient with von Recklinghausen’s neurofibromatosis who presented with sudden hoarseness is discussed. Results: A 33-year-old man with a personal and family history of von Recklinghausen’s neurofibromatosis, with a previous left vocal cord paralysis due to a neck surgery, was remitted because of a sudden hoarseness. The laryngoscopy showed a bilateral vocal cord paralysis, and neck exploration revealed a painful, left cervical mass. His endoscopic and radiological findings are shown. The management, treatment and evolution are discussed. Conclusion: The course of von Recklinghausen’s neurofibromatosis can be dramatic, requiring multiple surgical interventions with consequent deterioration of life quality, as the development of neurogenic tumors persists throughout the life of the patient.

A227 Clinical findings and acoustic analysis in patients with laryngeal tuberculosis L. Sanz Lopez1*, J. Sistiaga Suarez, A. Lara Peinado, M. Rodriguez Paradinas, T. Rivera Rodriguez 1 Madrid, Spain Introduction: Laryngeal tuberculosis (LT) is the most frequent granulomatous laryngitis (1.5–2%). Despite being a rare entity nowadays, we are witnessing an evident incidence raise in our country. Bronchogenic dissemination presents as the commonest pathogenic mechanism, followed by the hematogenous and lymphatic ones. Materials and methods: We present two patients who were 25 and 28 years old and complained of dysphonia, dysphagia and discomfort. Both were studied by telelaryngoscopy and stroboscopy. We recorded their voices and used the Medivoz computer software to perform the acoustic analysis. Finally we treated them for 6–9 months with four tuberculostatic agents and compared the results before and after treatment. Results: One of the cases presented an active pulmonary tuberculosis as well as a pharyngeal ulcer. They showed diffuse and bilateral laryngitis and left monocorditis respectively, both preserving the mucous wave. Mycobacterium tuberculosis grew in sputum samples and biopsies from one of the patients showed granulomas. Case 1: GRABS scale value was 6, S/E ratio 13.5/9.5, Jitter 5.8, Shimmer 15.2 and HNR 12. Case 2: GRABS value 5, S/E ratio 9/7, Jitter 6.7, Shimmer 18.6 and HNR 9. The phonetogram and spectrogram parameters came back to normality at the acoustic analysis after treatment. Conclusion: Laryngeal tuberculosis should always be ruled out when studying a chronic laryngitis. This relevant entity has a very specific treatment and cures leaving no residual voice changes in the acoustic analysis, as we proved, but may be easily misdiagnosed.

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A228 Co-existence of laryngeal squamous cell carcinoma and thyroid papillary carcinoma in a non-smoker female patient M. Dadgarnia*, M. Vahidi, A. Ahsani, S. Amiri Department of Otolaryngology, Head and Neck Surgery, Shahid Sadoughi University of Medical Sciences, Yazd, Iran Background: In the head and neck region, although squamous cell carcinoma is the most common malignant tumor, especially in the smoker and alcoholic male patients, multiple primary malignancies are a rare condition. Case report: A 90-year-old female presented with a thyroid mass since 4 months ago. The patient did not have any history of smoking, alcohol drinking or irradiation. On physical examination the patient had a firm and fix thyroid mass (4 9 5 cm). A fiberscoptic examination of the larynx revealed fixation of right true vocal cord and a lesion involving the right true and false vocal cord. Direct laryngoscopy and biopsy was done that pathologic report revealed the presence of squamous cell carcinoma surrounded by benign papilloma. Aspiration cytology of the thyroid mass demonstrated papillary carcinoma. The patient underwent total laryngectomy and thyroidectomy. Discussion: There are a few reports of cases in which malignant transformation has been observed in the absence of any carcinogenic causes, smoking, alcohol drinking or radiation. In these situations other factors may be relevant such as human papilloma virus and malignant transformation of laryngeal papilloma can occur without being detected histologically. In this case we could not find any relationship between thyroid cancer and laryngeal squamous cell carcinoma. Conclusion: Multiple primary malignancies in head and neck can be encountered in patients without having any recognized risk factor. This report demonstrates the importance of the need for a greater awareness in the patient with neck mass that is suspicious for malignancy.

A229 Combined reconstructive surgery of larynx and trachea M. Bagirov1, D. Zabolotny2, I. Bagirova2* 1 National Medical Academy for Postgraduate Training, Kiev, Ukraine; 2Institute of Otolaryngology, Kiev, Ukraine The treatment of laryngotracheal combined diseases remains one of the most complicated and unresolved issues of respiratory surgery. Methods: 311 patients with combined laryngotracheal diseases (93.3%) and injuries (6.7%) were treated (323 operations). Primary group (67%)—patients with benign stenosis, most of them had tracheostomy (75%) as a first stage of their treatment or multistage reconstructive operations (10%). Complimentary diseases and other organs injuries were diagnosed in 61 cases, all of which required an extensive surgical operation. In 37 cases (15.3%) with circumscribed and granulation stenosis an endoscopic method of treatment was

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 applied. Different kinds of reconstructive operations were applied in 274 cases (88.1%). Regardless of the area of lesion, we believe that the radical resection with simultaneous organs reconstruction is the most efficient operation in that case. Results: The new approaches, developed and applied by our team, have substantially improved the treatment results for this category of patients and enabled the fastest possible reconstruction of organs. 62.6% of our patients underwent this type of operation. In the rest of the cases (37.4%) we applied defect suture, circular laryngotracheal anastomosis, cicatrice treatment with insertion of T-shaped drain. Complications were observed in 24 cases (7.7%). 8 patients (2.6%) died. Summary: In cases of circumscribed and granulation stenosis of trachea and larynx endoscopic surgery methods make sense. Radical resection with simultaneous organs reconstruction is our top priority method.

A230 Comparison of biofilm formation on voice prostheses made of polyurethane and medical grade silicone: a pilot study M. Leonhard1*, D. Moser2, A. Reumueller1, G. Mancusi1, W. Bigenzahn1, B. Schneider 1 Department of Otorhinolaryngology, Medical University of Vienna, Vienna, Austria; 2Department of CranioMaxillofacial and Oral Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria Background: In laryngectomized patients, voice prosthetic biofilm formation is a well studied, but still unsolved problem. Several studies have been investigating on improving material resistance to yeasts and bacteria in order to extend the device lifetime. Recently, a new voice prosthesis Phonax by Heimomed (Germany) made of thermoplastic polyurethane was introduced for voice rehabilitation of laryngectomized patients. Methods: Five laryngectomized patients were equipped consecutively with Phonax and Provox2 voice prostheses. Microbial analysis of the collected prostheses was performed with standard microbiological methods. Biofilm formation and infiltration into the prosthetic materials were illustrated using scanning electron microscopy, fluorescence microscopy and thin section microscopy. Results: Candida species and oropharyngeal bacteria were identified as main colonizers of the esophageal sites of both prostheses. Microscopic imaging revealed differences in material surfaces, biofilm composition and infiltration morphologies; although the roughened surface of Phonax might enhance initial microbial adhesion, the polyurethane material seems to destabilize biofilm architecture and be less susceptible to biofilm infiltration. Conclusions: Microbial surface colonization of Phonax is not different in quality and quantity from conventionally medical grade silicone as used in Provox2 voice prostheses. However, the polyurethane material seems to reduce biofilm stability and infiltrative processes.

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A231 Complications of microlaryngoscopic laser CO2 surgery in patients with supraglottic carcinomas: our experience in the last 7 years ´ . Mun˜oz, P. Blanco, F. Del Rey*, J. Go´mez, A L. Sgambatti, J. Del Pozo, R. De La Fuente Hospital Clinico Universitario De Salamanca, Salamanca, Spain Objective/hypothesis: To investigate the incidence of complications in laryngoscopic laser surgery of supraglottic carcinomas. Study design: Descriptive and retrospective review at a tertiary referral center. Methods: We reviewed the 22 cases of supraglottic carcinomas treated with laryngoscopic laser CO2 surgery at our department between 1 January 2001 and 1 January 2008. We describe the sex and the age, the TNM stage, complementary use of chemotherapy and/or radiotherapy, the requirement of neck dissection and the complications before surgery. Results: A total of 22 patients, 1 woman (4.55%) and 21 men (95.45%) with average age of 65 years old were identified. The TNM stage showed: T2N0M0 10 (45.45%), T2N2M0 5 (22.73%), T1N0M0 4 (18.18%), T3N0M0 2 (9.09%), TisN0M0 1 (4.54%). 16 patients (72.73%) required only one laser surgery and 6 patients (27.27%) required repeat it. Neck dissection was required in 18 cases (81.82%). Tracheotomy was needed in 9 patients (40.91%). In addition to surgery 3 patients (13.64%) were treated with induction chemotherapy and radiotherapy and 6 (27.27%) with radiotherapy alone. The main complications described: bleeding episode in 3 (13.63%), aspiration in 8 (36.36%), dysnea in 3 (13.63%), cutaneous fistula in 2 (9.09%), tracheobronchial infection in 2 (9.09%), neck pain in 2 (9.09%), emphysema in 1 (4.54%). Conclusions: laryngoscopic laser CO2 surgery management of supraglottic carcinomas is an effective alternative to classic open surgery and can be performed safely with and acceptably low complication rate.

A232 Congenital anterior glottic web: surgical management and anatomical observation M. Amir*

Withdrawn

A233 Cysts of the larynx in children L. Zawadzka-Glos1*, M. Jesionowska-Jablonska1, M. Brzewski2, A. Biejat2, M. Frackiewicz1 1 Department of Paediatric ENT, The Medical University of Warsaw, Warsaw, Poland; 2Department of Paediatric Radiology, The Medical University of Warsaw, Warsaw, Poland

1101 Cysts of the larynx may appear in different regions of a larynx. Symptoms of laryngeal cysts depend on the size and localization of the cyst and include: change in the timbre, silent weeping, hoarseness, dysphagia, laryngeal stridor and dyspnoea.The diagnosis of laryngeal cyst is based on direct laryngoscopy. A respective analysis of 10 cases of laryngeal cyst in children treated in the Department of the Paediatric ENT in Warsaw between 2000 and 2008 was made.The authors analyzed problems with reaching the right diagnosis and methods of treatment.

A234 Does laterality of the vocal fold exist? I. Hocevar-Boltezar*, M. Sereg-Bahar, A. Jarc University Medical Center Ljubljana, Ljubljana, Slovenia Background: It is not clear why polyps arise in some patients on their left and in others on their right vocal fold. The aim of the study was to find a possible connection between the laterality of the hand, foot or eye and the side of the vocal fold polyp. Methods: 100 patients (48 M, 52 F) with vocal fold polyp were included. The patients were tested for the laterality of hand, foot and eye. 72% of patients fulfilled the Voice Handicap Index (VHI) questionnaire. The data on smoking, vocal load at work, possible vocal abuse and voice therapy were obtained from documentation. The patients with right vocal fold polyp (51 patients) were compared to the patients with left vocal fold polyp (49 patients) with regard to their laterality, results of VHI, and medical documentation data. Results: A polyp on the left vocal fold appeared in 12/15 lefthanded and in 37/85 right-handed patients, and in 18/26 patients with dominant left eye and 8/74 patients with dominant right eye what represented a significant difference. No significant differences were found between the subgroups with regard to foot dominance, age, gender, smoking, vocal load at work, vocal abuse, voice therapy, and results of VHI. Conclusion: The results of the survey indicate a possible influence of the dominance of left hand and eye on the vocal fold polyp side. In order to find an explanation for this phenomenon further neurological and neuroradiological investigation is necessary.

A235 Endoscopic laser surgery for laryngeal malignancy R. Srivastava1*, S. Gandhi2 1 Sahara Hospital, Luchnow, UP, India; 2Voice Disorder Clinic, Deenanath Mangeshkar Hospital, Pune, India Objective: To assess the laser management of Tis, T1, T2 tumors of the larynx, and debulking of large tumors for palliation and avoiding tracheostomy. Methods: This is a review of 54 cases of laryngeal malignancy operated between 2001 and 2008 with CO2 and diode laser. 34 cases were of early glottic carcinoma for whom cordectomy was done. 9 cases came in respiratory distress and endoscopic laser debulking was done to avoid tracheostomy. In 11 cases debulking was done as a palliative measure. Results: In 21 cases of T1a, five cases of T1b and eight cases of T2a laser cordectomy was done. All 29 patients are under observation. Three of them were given radiotherapy on follow up. Patients

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1102 have good postoperative voice and have shown no recurrence till date. Nine patients came with respiratory distress due to obstructive supraglottic mass. Debulking was carried out with diode laser and tracheostomy was avoided in seven patients. Histopathology revealed evidence of malignancy in all nine cases. Conclusion: In carefully selected patients of early glottic carcinoma endoscopic laser surgery has given excellent results. This procedure avoids morbidity and side effects associated with radiation and gives one session therapy as compared to four to six weeks therapy with radiation. Endoscopic laser surgery for early glottic carcinoma is a good treatment alternative in terms of oncological as well as functional results.

A236 Endoscopic laser surgery for compromised airway S. Gandhi* Voice Disorder Clinic, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India Idea: Surgical management of compromised airway is challenging due to multiple sittings required in management, its associated morbidity, high cost and delayed results. Endoscopic laser surgery has shown definitive advantages in management of these cases. Method: 268 cases of compromised airway were operated with CO2 laser (Lumenis) and diode 810 nm (Diomed) laser. The cases included airway obstruction due to congenital lesions 14 (5.2%), neck trauma 27 (10%), intubation trauma 98 (36.6%), chemical trauma 8 (3%), bilateral abductor palsy 77 (28.7%), infection 14 (5.2%), benign laryngeal tumors 11 (4.1%) and iotrogenic 19 (7%). Digital video stroboscopy, flexible laryngoscopy, pulmonary function test, voice analysis and imaging was used pre and post surgery. Results: The longest follow up was for 8 years. 64 (23.9%) patients were admitted with tracheostomy. Tracheostomy was done in the hospital for 10 cases (3.8%). High Frequency Jet Ventilation (HFJV) /intubation was used in 194 (53.33%) cases. 56 (75%) of 74 cases were successfully decannulated. Conclusion: Advantages of endoscopic laser surgery: 1. 2. 3. 4. 5. 6. 7.

Good anatomical exposure Near bloodless field Surgery can be planned in stages Tracheotomy can be avoided Less edema, fibrosis, synechae Aseptic technique Less surgical time, less morbidity and hospitalization.

A237 Eosinophilic granuloma in the larynx: a very rare case report M. Dadgarnia1*, S. Taghipour2, M. Dehghan Bahabadi1, G. Karimi1 1 ENT Department,Yazd Shahid Sadoughi University of Medical Sciences, Yazd, Iran; 2Pathology Department,Yazd Shahid Sadoughi University of Medical Sciences, Yazd, Iran

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Introduction: Langerhans cell histiocytosis has been studied over the years; it has acquired several different names as new information was derived about the disease and the syndromes that accompany it. Some of the more common terms previously used to refer to this disorder include histiocytosis X and eosinophilic granuloma. Case report: A 49-year-old woman comes to our ward with hoarseness, dysphagea and odynophagea since 6 months ago. In physical examination she has ulceration and lesion on the lingual surface of epiglotte and right aryepiglottic fold. Under general anesthesia incisional biopsy was done. In histopathological findings there was fibrocollagenous connective tissue that was severely infiltrated by inflammatory cells composed of proliferation of foamy and vacuolated histiocytes with variable admix true of neutrophilis, eosinophils lymphocytes and plasma cells. Patient referred to oncologist ward for further treatment. Discussion: Eosinophilic granuloma is a benign disorder that affects children and young adults, particularly male patients and it is primarily characterized by single or multiple skeletal lesions. The solitary bone lesion may be asymptomatic unifocal lesions occurring at certain sites such as mastoid process that it may extend in to the middle ears. Presentation of eosinophilic granuloma as a laryngeal solitary lesion has been not described yet. Conclusion: Langerhans cell histiocytosis is a rare disorder that primarily affects children but is also found in adults of all ages. Although some forms of this disease were originally described over a century ago, it has only been recently that it has begun to receive more attention.

A238 Excercise induced laryngeal dysfunction in children who had laryngomalacia as new-borns M. Hilland1*, J. Heimdal2, L. Sandvik1, O. Roksund2, T. Halvorsen2, J. Olofsson1 1 Department of Oto-Rhino-Laryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway; 2 Department of Oto-Rhino-Laryngology/Pediatrics, Haukeland University Hospital, Bergen, Norway Introduction: Laryngomalacia is the most common congenital condition causing stridor in new-borns. According to present literature, laryngomalacia and its corresponding breathing difficulties is expected to diminish completely by the age of 18–22 months. Supraglottic obstruction of the larynx causing respiratory distress during exercise have been demonstrated and referred to as exercise induced laryngomalacia (EIL) in young athletes. Aims: The objective of this study is to reveal whether laryngomalacia in new-borns has any relevance for EIL in later childhood. Materials and methods: A retrospective study has been performed on medical reports of new-borns who were admitted to the hospital between 1990–2000 and coded with laryngomalacia as their main presenting symptom. Thirty-one children (mean age 2 months) had their diagnosis confirmed by paediatricians or otorhinolaryngologists. Six children with serious co-morbidity affecting performance in any way were excluded from the study. The remaining 25 cases are now invited to a follow up study 9– 18 years after diagnosis. The children/parents are asked to answer a questionnaire focusing on respiratory distress during daily life, physical activity and sport. All cases are invited to an examination

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 with continuous videolaryngoscopy during exercise on a treadmill (CLE-test) as well as a spirometry. Preliminary results: The results will be presented for all patients in this cohort. So far, 6 children (10–16 years) have been examined. Four out of 6 subjects reported signs of exercise-induced respiratory difficulties before testing. All subjects showed a flattened inspiratory spirometric curve. Five out of 6 subjects showed signs of redundant mucosa over the arytenoids and aryepiglottic folds at rest. The laryngeal motion was normal at rest and at moderate exercise levels in 5 out of 6 subjects. However, an extensive exercise induced inspiratory synchronous medialization of the dorsal part of the aryepiglottic folds was demonstrated in all subjects. Inspiratory stridor was apparent in all subjects at maximal effort. Summary: Although the number of subjects is too small to conclude firmly at the present time, there seem to be a relation between congenital laryngomalacia and EIL in older childhood or adolescence. Considering EIL being an important differential diagnosis to exercised-induced asthma, a proper examination of laryngeal function is warranted for patients with exerciseinduced respiratory difficulties and a history of congenital laryngomalacia.

A239 Functional results in a complex head and neck surgery case F. Fauvet*, P. Schultz, C. Debry ORL HNS Department, Hoˆpital de Hautepierre, Strasbourg, France Introduction: This study aims at analyzing speech disorders and compensation mechanisms developped in a complex head and neck surgery case. Materials and methods: Spontaneous conversation of healthy speakers (n = 10) and of a patient who underwent total pelvi-glossectomy and anterior mandibulectomy with reconstruction for an epidermoid carcinoma (T4N2cM0) is recorded. Acoustical analyses are focused on the first three formant frequencies for vowels /i, a,u/, on the burst spectrum and on the Klatt’s VOT for plosive consonants /p, t/. Speech intelligibility is evaluated by two juries, one expert and one naive. Results: Elocution has not shown major deterioration of pitch and speech rate. 5 months after surgical treatment and speech rehabilitation, Klatt’s VOT duration values became similar to the Klatt’s VOT duration values of the control speakers. Timing constraints of consonant productions were perturbed and affected the glottal signal and articulatory coordination: voicing pulses of voiced plosives disappeared. Progressively, F1 and F2 values of /i, a, u/ varied and the acoustic vowel space augmented. F3, with lower values at the first postoperative recording, tended gradually to resemble ‘‘standard’’ values. Conclusion: A very early rehabilitation based on articulatory motor targets and initiated before recovery of phonation significantly improved segmental and suprasegmental speech components. Accurate phonetics data including perceptual measurements and acoustic analyses open new therapeutic perspectives. Keywords: Vocal tract surgery, Speech therapy program, Precociousness, Articulatory motor targets, Speech intelligibility, Acoustic analyses.

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A240 Giant internal laryngocele E. De La O Corrochano*, M. Cisternas Bittencourt, G. Fernandez Rodriguez, M. De Saa Alvarez, C. Salazar Cabrera, G. Pardo Romero, M. Aparicio Perez Department of Otorhinolaryngology, Head and Neck, Hospital San Pedro de Alcantara, Ca´ceres, Spain Introduction: Laryngoceles are a rare entity consisting of abnormal laryngeal saccule dilatation, of still unclear etiology, probably in relation with overpressure or obstruction that may be due to tumor development. The symptoms are hoarseness, coughing, odynophagia, dysphagia and less frequently dyspnea. When thyrohyoid membrane perforation occurs, they can protrude as a cervical mass. Occasionally they can coexist with a larynx malignancy, therefore surgical treatment is recommended to exclude this possibility. Method: The case of a 71-year-old woman who consulted with acute dyspnea is discussed. Results: A non-smoker 71-year-old woman with a long-term history of hoarseness consulted with a 3-month history of progressive dyspnea. The endoscopic exploration showed a cystic formation in the left pharyngoepiglottic fold that distorted the ipsilateral larynx. A cervical CT showed an oval air-filled formation of 35 mm diameter, with partial upper airway obstruction. The patient underwent endoscopic CO2 laser-assisted resection, and showed disappearance of the dyspnea and spectacular improvement of her voice quality. Conclusions: Laryngoceles are a rare entity, with unclear etiology. A laryngocele is a possibility in patients with a history of long-term hoarseness and a progressive dyspnea. The endoscopic CO2 laserassisted resection is a possibility in internal laryngoceles.

A241 Hemodynamic changes during orotracheal intubation with the glidescope and direct laryngoscope M. Mahjoubifard*, S. Borjian borrojeni Zahedan University of Medical Sciences, Zahedan, Iran Background: Hemodynamic changes during intubation are extremely important especially in patients with a history of coronary artery disease and arrhythmia. The aim of this study was to compare the hemodynamic changes during video laryngoscopy (glidescope) and the conventional method of direct laryngoscopy. Methods: This randomized double-blind clinical trial recruited 200 male patients undergoing elective orthopaedic surgery. Heart rate (HR) and mean arterial blood pressure (MABP) were measured before, at the time of induction and every minute for 10 min following intubation. Results: Changes of MABP were significantly less in the glidescopy group compare to direct laryngoscopy group (P = 0.001). No significant change was observed between the HR of the two groups. Conclusion: Glidescopic method of orotracheal intubation is considered advantageous over the conventional method for its less alteration of MABP. Keywords: Orotracheal intubation, Glidescope, Hemodynamic changes.

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A242 Intralaryngeal stents in the treatment of stenosis of the larynx J. Wojtowicz*, W. Szyfter ENT Clinic, Poznan University of Medical Sciences, Poznan, Poland The treatment of laryngeal stenosis and restenosis or sublaryngeal region requires often realization of many surgical interventions. This leads to decreases of chondral scaffolding of neighbourhood larynx or subglottical region as well as the initial section of trachea hugging first of all front their wall. Proposed technique of surgicalt treatment operating on the narrowing of larynx and sublottical region of the larynx on aim of behaviour of front wall neighbourhood is restricted, especially in whose cases at which the technique of Montgomery T-tube was applied previously. In material has been represented 6 cases of use the treatment associated the narrowing of larynx and the subglottical region of the larynx depending on removal the of cicatrical changes with CO2 laser surgery as first step of treatment and as secondary Introduction in operated field the silicone drain placed and fixed by transverse sutures by whole continuity of neck on level of the stent. The local results of treatment of narrowing were good, the necessity of use of temporary tracheotomy has been excluded. In the opinion of patients this method gives the better quality of life, because eliminated difficulties due to tracheotomy and her implications.

A243 Is frozen section reliable in transoral CO2 laser assisted laryngeal tumors resection? N. Matar*, G. Lawson, M. Remacle Otolaryngology-Head and Neck Surgery Department, Mont-Godinne Hospital, Yvoir, Belgium Objective and introduction: Transoral laser-assisted partial laryngectomies have proved to be efficient for properly selected cases. One criticism against laser-assisted resection is the difficulty of interpretation of histological specimens. Our goal is to assess the reliability of frozen section in this setting by comparing its results with those of routine histology. Materials and methods: We retrospectively reviewed the charts of 96 consecutive patients who underwent cordectomies in our department, using the CO2 laser Acublade system (Lumenis, Santa Clara, CA). Age, sex, staging of the tumor, previous treatments, type of cordectomy, frozen section and routine histology results were analyzed. Results: 96 patients fulfilled the inclusion criteria. Seven had more than one surgery, so the total number of surgeries was 103. 29 patients had dysplasia (10 in-situ carcinoma), 52 had T1, 17 had T2 and 5 had T3 epidermoid carcinoma. According to the ELS classification, we performed a subepithelial cordectomy in 23 patients, subligamental cordectomy in 33, transmuscular cordectomy in 11, total cordectomy in 6 and extended cordectomy in 30. Most of the patients did not have any previous treatment. The mean number of margins per surgery was 2.65. Routine histological examination confirmed frozen section in 93.3% of the interventions. Cordectomy was extended in 10% of the interventions based on frozen section results. In only 2.9% of the cases positive margins were missed.

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Discussion and conclusion: Frozen section is reliable in transoral laser-assisted partial laryngectomies when performed by experienced surgeons and pathologists. It improves complete tumor resection in one surgical session.

A244 Juvenile-onset laryngeal papillomatosis: clinical features, quality of life and voice at adult age T. Ilmarinen1*, H. Nissila¨2, R. Roine3, P. Rasanen3, H. Rihkanen1, P. Pietarinen-Runtti1, A. Pitka¨ranta1, L. Aaltonen1 1 Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Central Hospital, Helsinki, Finland; 2Department of Speech Sciences, University of Helsinki, Helsinki, Finland; 3Helsinki and Uusimaa Hospital Group, Helsinki, Finland Objectives: To evaluate clinical features, quality of life and voice in patients with a history of juvenile-onset laryngeal papillomatosis. Methods: All patients with juvenile-onset (age at diagnosis \ 17 years) laryngeal papillomatosis treated at Department of Otorhinolaryngology, Helsinki University Central Hospital during 1975–1994 were invited to an outpatient visit in year 2008. A control patient was matched for each study subject according to sex, age (±5 years) and smoking habits. Videolaryngostroboscopy was performed and a voice sample recorded. Questionnaires were used to assess health related quality of life (15-D) and subjective voicerelated handicap (VHI = voice handicap index). Results: Eighteen out of 32 patients joined the study (12/18 male). Median age was 5.4 years (range 0.5–16.7 years) at diagnosis and 40.3 years (range 22.0–71.6 years) at the time of examination. Patients had undergone a median of 11.5 laryngeal procedures (range 1–70). Four patients had previously had a tracheotomy. Papillomas were found in 4 patients. Changes in the gross anatomy of larynx, scar tissue and gap between vocal folds during phonation were commonly seen. Percent jitter, percent shimmer and noise-to-harmonics ratio were all statistically significantly higher for patients than for controls. Fourteen patients considered their voice mildly (n = 10) to moderately (n = 4) disordered. Median VHI score was 19.5 for patients and 11 for controls. In general health related quality of life there was no difference between groups. Conclusions: Our findings suggest that patients with juvenile-onset laryngeal papillomatosis have an increased risk for laryngeal pathology and voice-disturbances at adult age.

A245 Laryngeal amyloidosis: case report and a review of literature I. Bartku1*, Z. Pokol2, I. Elek1, E. Fu¨le1, I. Fu¨lo¨p1 1 Hungarian Society of Oto-Rhino-Laryngology, Head and Neck Surgery; 2Department of Hematology, Josa´ and ra´s Teaching Hospital, Nyiregyha´za, Hungary Objective: Amyloidosis of the upper aerodigestive tract is relatively rare, although the larynx is a common site of involvement in the head

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 and neck isolated cases. The amyloidosis is characterized by the extracellular deposition of fibres, the amyloid proteins. It can be localized or systemic, and classified as primary or secondary. This study was made to review the laryngeal amyloidosis. Method: We report a case of a 48-year-old man with hoarseness and dyspnea. He underwent a microlaryngoscopy and a cold excision. An amyloid mass was removed from the right true vocal cord. After surgical intervention a general examination was performed seeking for systemic involvement. Presenting this case and with a review of literature we studied clinical signs, manifestations, histopathological characteristics, diagnosis, treatment, and the appropriate workup for systemic involvement. Results: The main presenting symptoms are hoarseness and dyspnea. The diagnosis is made by direct laryngoscopy and biopsy. The treatment is surgical, which can be cold excision or laser surgery. The laryngeal amyloidosis can be localized disease, but important to notice that it can have systemic involvements, and can related to myeloma multiplex, so a workup for systemic amyloidosis must be performed. Conclusions: Laryngeal amyloidosis is a rare disease, which can be succesfully treated by laser microsurgery or cold excision. The results of treatment are excellent, but a close and long-term follow-up is required, the recurrences are common and can be manifested after several years.

A246 Laryngeal cysts frequency and localisation within pseudotumors of larynx: 15 years experience P. Vasiljevic1*, R. Kosanovic1, P. Trickovic1, M. Vasic1, V. Saranovic1, Z. Ivankovic1, Z. Dudvarski2, K. Stankovic3 1 City Hospital Zvezdara, Belgrade, Serbia; 2ENT and MF Institute, Clinical Center of Serbia, Belgrade, Serbia; 3 Pediatric ENT Department Laryngeal cysts are very rare benign lesions of the larynx. Macroscopically they look like tumors but because of their biological and histological nature, they are not real neoplasm so they are classified as a pseudotumors of the larynx. Usually laryngeal pseudotumors become as result of inflammation, traumatic or degenerative lesion. Pseudotumors of the larynx are painless, slowly rising lesions and only when they reach categorical size they are clinically manifested. Clinical signs and symptoms depends on age, size and localization of laryngeal cysts. As they can affect all age groups, symptoms, clinical signs and physical findings are different and should be considered separately since the presentations can be quite different. Diagnosis is made after taking detail medical history, complete ENT examination, videostroboscopy, CT scanning of the larynx, laryngomicroscopy and histoptahological verification. The aim of our study was to present the incidence and the most frequent localization of laryngeal cysts within all pseudotumors of the larynx during 15 years period. From 1993 till 2007 at ENT Department of the City Hospital ‘‘Zvezdara’’ in Belgrade, we have been treated 783 patients with laryngeal pseudotumors. After completed treatment we had diagnosed 81 (10.3%) patient with laryngeal cysts. The main localization of the cysts was on the vocal cord. All patients with laryngeal cysts were treated with surgical excision in laryngomicroscopical technique.

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A247 Laryngeal tuberculosis E. De La O Corrochano1*, M. Cisternas Bittencourt1, L. Sgambatti Celis2, G. Fernandez Rodriguez1, F. Ramos Puerto1, M. Garcia Jimenez1, J. Herrero Herrero1 1 Department of Otorhinolaryngology, Head and Neck Surgery, Hospital San Pedro de Alcantara, Ca´ceres, Spain; 2 Department of Otorhinolaryngology, Head and Neck Surgery, Hospital Clinico Universitario, Salamanca, Spain Introduction: One-third of the world population is infected by the Mycobacterium tuberculosis. The great majority are pulmonary tuberculosis, while the laryngeal localization accounts for less than 1% of all cases, and may be primary or secondary to dissemination from other localizations. Methods: We discuss the medical records of four cases of tuberculosis of the larynx. Results: From 2005 and so far we have had four cases of laryngeal tuberculosis, the ages ranged from 20 to 82 years. Three of the four patients had concomitant pulmonary tuberculosis, and the other patient had isolated laryngeal tuberculosis with coexistence of a malignancy of the larynx, that required additional surgery. Laryngoscopic images are shown. The treatment and evolution of the patients is described. Conclusions: There has been a recent resurgence of tuberculosis in the developed countries, although the laryngeal localization is still rare, it must be suspected as a differential diagnosis in laryngeal lesions. The recommended treatment is the standard anti-tuberculosis chemotherapy, with appropriate follow-up to exclude the possibility of coexistence with a malignancy, that may require other surgical techniques.

A248 Laryngotracheal restenosis: what are the difficulties? R. Jovic*, K. Canji, D. Dragicevic, S. Mitrovic, Z. Komazec University ENT Clinic, Novi Sad, Serbia Aim: The aim of the study is to analyse causes of the development and treatment abilities for laryngotracheal restenosis. Materials and methods: Out of 41 patients who were treated for laryngotracheal stenosis (2002–2008), 19 (46.4%) patients had restenosis after endoscopic and/or surgical procedures. Restenosis after open surgical procedure occured in 4/19 (21%) patients, after endoscopic resection in 7 patients and after combination of open surgery with CO2-laser in 8/19 (42.1%) patients. Stent was placed at the stenotic part in 7 patients. Results: Out of the 16 (84.2%) surgicaly treated patients, 10 (62.5%) underwent partial cricotracheal resection (to 6 cm) with thyrotracheopexy, 4 (25%) had laryngotracheal reconstruction, and 2 (12.5%) were treated with tracheal resection and cricotracheopexy. One patient had only endoscopic intervention. After second resection one patient remained with trachea of 4.5 cm (6 tracheal rings) in length. Laryngeal release was performed in 7 patients.

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1106 Nasotracheal tube (5 mm) was used for 3 days to 2 weeks to protect upper airway in 5 patients. Two patients were not suitable for surgical treatment and both are with tracheostomy. One patient died with central apnea provoked with Anafranil. Restenosis occured in one patient with tuberculosis. Fiftheen out of 19 (78.9%) patients with restenosis were without tracheostomy. Results were worse in comparison with results achieved in 22 patients who were primarily treated at our institution and all are without tracheostomy with only one revision surgery. Conclusion: Restenosis must be avoided with better planned and selected surgical technique since it makes success rate worse.

A249 Laryngotracheoplasty with autologous cartilage rib graft in children P. Pavlov*, E. Tzvetkov, L. Mhuli Saint-Petersburg State Pediatric Medical Academy, Saint Petersburg, Russia Introduction: Subglottic stenosis (SGS) is still relevant problem of present-day otorhinolaryngology. Methods: We retrospectively reviewed the charts of 17 patients who underwent treatment for SGS by using the single-stage laryngotracheoplasty (SSLTP)—5 patients and multiple-stage laryngotracheoplasty (MSLTP)—12 patients between September 2000 and September 2007 at the ENT Department of SaintPetersburg State Pediatric Medical Academy. The ages of the children who underwent SSLTP ranged from 2 to 36 months (mean 14.4 months, SD 12.8 months) and who underwent MSLTP ranged from 24 to 216 months (mean 78.0 months, SD 61.3 months). Among them 14 were tracheostomy-dependent prior to reconstruction. Technique: SSLTP involves a mid-line incision made anteriorly in the cricoid and upper trachea with nasotracheal intubation which is made by inserting an endotracheal tube with maximum size for given child’s age. Then the resected cartilaginous part of right fifth rib is carved into the spindle-shaped form, interposed and fixed between the cut edges of the cricoid cartilage and tracheal rings with the perichondrial layer facing the airway lumen. MSLTP utilizes the endotracheal indwelling rolled silicone stent above the tracheostomy tube to stabilize the graft. Results: 1) 2)

The extubation rate from SSLTP was 100% (5 out of 5). The decannulation rate from MSLTP was 91.6% (11 out of 12).

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 We have performed a retrospective review of all patients treated with primary, curative Carbon Dioxide or Holmium-YAG laser resection of head and neck squamous cell cancer, excluding oral cavity and lip. Relevant details were found in 33 patients. Any recurrences occurring after 5 years from the original surgery were called new primaries. Of 18 T1a cancers of the glottis treated, all were controlled with local laser resection. Four T1b cancers were treated, all of these recurred and required radical surgery and/or radiotherapy. Five out of 6 (83.3%) T2 glottic cancers were succesfully treated with laser resection, as were all early (stage T1 and T2) oropharyngeal cancers and one T1 supraglottic cancer. Two post radiotherapy recurrences, a T2 glottic and T1 supraglottic were also successfully treated by local laser resection. The average follow up is 26.6 months, which is the mean of the time taken for the cancer to recur, or the time disease free post treatment.

A251 Leiomyosarcoma of the larynx Z. Novakovic*, P. Spiric, S. Spiric, D. Vranjes, A. Aleksic ENT Clinic, Clinical Centre Banjaluka, BanjaLuka, Bosnia and Herzegovina Leiomyosarcoma is a malignant tumor of smooth muscle cells. Leiomyosarcoma of the larynx is extremely rare, only 50 cases were reported in the available literature. Diagnosis is difficult, based on immunohistochemical studies. Patients are usually treated by surgery and postoperative radiotherapy. We analysed a case of a 49-year-old man, smoker who reported 6-months lasting symptoms of hoarseness. After 3 MLS and biopsies taken,T1bN0M0 tumor was established. First two biopsies taken showed dysplasia of low and medium grade. Because of persistent hoarseness and unsatisfactory local finding, the third bioptic sample was immunohistochemically analysed. Final diagnosis was leiomyosarcoma of the larynx. Our patient underwent bilateral chordectomy. Borders of resection field were negative and patient did not undergo postoperative radiotherapy. 1 year after operation, the left-sided neck metastatic lymph nodes appeared. Therefore the patient underwent modified neck dissection. 4 years follow up after neck dissection and 5 years follow up after chordectomy there is no signs of local recurrence or metastasis. Because of difficulty in final diagnosis establishing, immunohistochemical studies must be a compulsory step of diagnostic algorithm of this kind of tumor. Treatment method differ from case to case. Survival rate should be justified by meta analysis because of small number of cases.

Conclusion: The above-named techniques make a marked increase in the airflow through the larynx and upper trachea and are effective and reliable for the surgical management of SGS.

A252 Leishmaniasis presenting to the otolaryngologist: a rare but important cause of persistent hoarseness

A250 Laser excision of early laryngeal cancer: a tertiary head and neck cancer centre experience

N. McCluney, M. Shakeel*, L. Santangeli, I. Hathorn, C. Anderson 1 Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK

H. AL-Reefy1*, M. Dilkes2, K. Ghufoor2, H. Mehrazad2 1 Royal National Throat Nose and Ear Hopsital, London, UK; 2St. Bartholomew’s Hospital, London, UK

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Objective: We report a rare case of laryngeal leishmaniasis in the UK, mimicking laryngeal candidiasis associated with chronic steroid inhaler use.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Methods: Case report and a review of the world literature concerning leishmaniasis. Results: Laryngeal leishmaniasis is a rare protozoal infection in the Western world. It is becoming more common however with increased foreign travel. It can be difficult to diagnose histologically and, because of its rarity, diagnosis is often delayed. It can also mimic malignant laryngeal disease and patients may therefore be subjected to significant and inappropriate treatment interventions. Conclusions: Leishmaniasis is a diagnosis to consider if initial treatment for persistent hoarseness has been ineffective, particularly in a patient who is at low risk for malignancy.

A253 Major anastomotic dehiscence (MAD) after cricotracheal resection and anastomosis (CTRA): risk factors, management, and outcomes C. Piazza*, G. Peretti, P. Nicolai University of Brescia, Brescia, Italy CTRA is applied to benign and neoplastic stenoses of the cricotracheal junction. Our aim is to describe risk factors, management, and outcomes of MAD. 107 patients received CTRA for inflammatory (73) or neoplastic (34) airway stenoses. A charts review identified 10 (9%) patients with MAD: 6 treated for postintubation stenosis, 2 for thyroid cancer infiltrating the airway, 1 for recurrential metastasis involving the trachea and oesophagus, and 1 for cricoid chondrosarcoma. Airway resection exceeding 5 cm was considered the main risk factor in 3 patients. In 1, a postoperative epileptic crisis caused MAD. Intense emesis in 3, concomitant thyroidectomy with central compartment neck dissection in 3, tracheo-oesophageal fistula in 2, and preoperative RT in 2 were thought to be responsible for MAD in the others. 3 patients had an association of 2 or more risk factors. Univariate analysis showed significant association between MAD and length of resection equal or superior to 5 cm (P = 0.007), preoperative RT (P = 0.02), and postoperative emesis (P = 0.007). MAD was managed by laryngectomy with free flap for oesophageal closure in 1 case and permanent tracheostomy in another 1 (both neoplastic stenoses after RT). The others (80%) achieved a patent airway after redo-CTRA (6), Dumon prosthesis (1), and Montgomery T-tube insertion for 1 month (1). Decannulation rate after MAD was 80%. Besides length of airway resection, other factors predispose to MAD. Preoperative RT should be considered a contraindication to CTRA. Moreover, postoperative management must include an aggressive antiemetic therapy.

A254 Manifestations of lipoid proteinosis in otorhinolaryngology M. Jalilian1*, H. Djalilian2, A. Djalilian3 1 Day General Hospital, 2University of California, Irvine, CA, USA3University of Illinois, Chicago, IL, USA Objectives: Lipoid proteinosis (LP) is a rare disorder characterized by widespread storage of hyalin in the skin and mucosal membranes of the upper respiratory tract. Otolaryngologic manifestations of LP can

1107 often be the initial presenting symptom. The purpose of this study is to familiarize the otolaryngologist with the head and neck manifestations of this disease. Methods: A case series of 6 patients in the last 3 years, aged 4 to 35, who presented with otolaryngologic symptoms that eventually led to the diagnosis of LP is presented. Results: The presenting symptom in all 6 cases was progressive hoarseness since birth or early childhood. The most common finding on head and neck examination was waxy appearing vocal cords (6/6), a thickened tongue (5/6), and skin papules on margins of eyelids (4/6). The rest of the case histories with pictures will be presented in detail. Conclusion: Otolaryngologists should be aware of the diagnosis of LP in a patient who presents with progressive hoarseness that started early in life. A thickened tongue along with skin findings are highly suggestive of this diagnosis.

A255 Office based BotoxÒ injection for adductor spasmodic dysphonia: our experience with a different technique M. Shakeel*, G. Thiel, A. Hussain Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK Introduction: The practice of laryngeal injections for a variety of voice disorders is well established. Various methods of delivering Botox to the vocal cords have been mentioned in the English literature, each having its advocates. Aim: We describe an easy and simple technique of injecting Botox into the thyroarytenoid muscles of the larynx in an office setting, using local anaesthetic and a channelled flexible laryngoscope. Technique: We use a flexible laryngoscope with a channel (Olympus ENT Type T3). The injection device is an Injector ForceTM (Olympus disposable injector NM), which has a working length of 165 cm with a 5 mm 25 G needle. The injection needle is primed using 1.8 ml of Botox at a dilution of 2.5 IU per 0.1 ml. The patient’s larynx is anaesthetised with a spray of 2 ml of xylocaine under direct visualization. The surgeon then performs the flexible laryngoscopy and positions the laryngoscope for injection into the thyroarytenoid (TA) muscle at mid-cordal level. The assistant places the needle under direct vision and injects the appropriate amount of Botox into the thyroaretynoid muscle. Results: We have used this technique in our voice clinic for the past several years. Seven patients with adductor spasmodic dysphonia received Botox injections at regular intervals in this way. No untoward effect because of the technique was noted and all of our patients, at all occasions tolerated the procedure very well. No procedure was abandoned. We have plans to objectively quantify patients’ comfort and satisfaction with this technique using validated tools.

A256 Organ preservation rate in transoral laser microsurgery (TLM) of advanced malignant tumors M. Bernal-Sprekelsen*, I. Vilaseca, J. Blanch, M. Caballero, M. Moragas, F. Sabater 1 Hospital Clinic, Servicio de ORL, Barcelona, Spain

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1108 Background: There is an ongoing controversy about oncologic and functional outcomes after TLM in locally advanced tumors. Goal: Functional results after TLM in locally advanced tumors of the larynx and hypopharynx. Materials and methods: Prospectively collected data (SPSS data base) of T3/T4 tumor patients treated primarily by TLM from Febraury 1998 to September 2007. Minimum follow-up of 12 months. The rates of temporary and definitive gastrostomy/tracheostomy were studied, as well as the rates for partial or total rescue laryngectomies. Results: Two-hundred and seven previously untreated cases were included. 120 supraglottic, 21 glottic, 31 anterior commissure and 35 pyriform sinus tumors. One-hundred and fifty-four cases were locally advanced: 136 T3 y 18 T4. Temporary and definitive gastrostomies were respectively performes in 6 cases (2.9%). A total of 24 temporary (11.5%) and 12 definitive (5.8%) tracheostomies were needed. Organ preservation was achieved 159 cases (76.4%) and function (deglutition) in 151 (72.6%). Depending on the vocal cord mobility the organ preservation rate was 72.7% for cases with reduced mobility and 61.5% for vocal cord fixation. The adjusted survival rate was 69% for stage III and 51% for stages IVA 51%. The adjusted survival rates for different tumor locations were: glottis: 94.7%; anterior commissure: 71.1%; supraglottis: 58.2%, and pyriform sinus: 38.5%. Conclusions: Many cases, if not most, would have undergone a total laryngectomy following prior indications. TLM for advanced stages and locally advanced tumors (T3/T4) achieves a high rate of larynx preservation, without impairing the survival rates.

A257 Pharyngocutaneous fistula after laryngectomy B. Boci*, P. Radovani, J. Dervishi, I. Zhilla University Hospital Centre of Tirana, Tirane¨, Albania Objectives: ‘Pharyngocutaneous fistula’ remains the most frequent and bothersome complication, after total laryngectomy, with several hypothetical causing factors. The scope of this study, as a result, will be ‘ Pharyngocutaneous fistulas’. Materials and methods: We examined the clinical material of laryngectomies performed in our clinic frrom 2001 to 2006. The series includes 120 cases which underwent total laryngectomy, with elective or radical dissection of the neck. 90 patients were evaluated as the third stage, 30 of the fourth. Results: In all the series fistula occurred in 51 patients (42%). Distributing according to years, a gradual lower occurrence was noted from 57.9% in 2001 to 15.8% in 2005. Main risk factors are dominated from the stage of tumor, poor oral hygiene and smoking. It is not in our practice preoperative radiation. Weight-loss and lower albumin represent a lesser risk. Conclusions: Opening of the mucosal barriers during a laryngectomy surgery, increase the risk of bacterial contamination of the wound, but the ground for a postoperative infection is laid by: 1. Risk factors of oncologic pathology 2. Incorrect application of basic surgical principles. There is no doubt that post-surgical infection plays an important part in creating PCF. Because of this we aim:—Infection’s prevention, taking into consideration risk factors and the rigorous application of basic surgical principles—as a clean-contaminated wound necessitates the use of prophylactic antibiotics— antireflux therapy continues for 7 days, whereas the nasogastric tube is removed on the tenth day. Keywords: Laryngeal carcinoma, Total laryngectomy, Pharyngocutanous fistula.

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A258 Pharyngoesophageal reconstruction after laryngopharyngo-esophagectomy S. Bertesteanu1*, D. Mirea2, R. Grigore1, D. Ionescu3, C. Popescu1 1 Head and Neck Surgery Department, Coltea Clinical Hospital, Bucharest, Romania; 2Euroclinic Hospital, Bucharest, Romania; 3University Clinical Hospital, Bucharest, Romania Malignant lesions of the pharyngoesophagus often require total laryngopharyngectomy and radical neck dissection. Circumferential pharingoesophageal defect represent one of the biggest reconstructive challenges. Following ablative surgery, proper threedimensional reconstruction is necessary for a good quality of life. To assess the esophageal sintetic prosthesis as a method of pharyngoesophageal reconstruction in patients who have cancer of the hypopharynx and cervical esophagus cancer, with low cost and early realimentation. Our experience is with 52 patients who underwent circular pharyngolaryngectomy with imediate reconstruction with pharyngo-esophageal prosthesis, transposition of colon, free jejunal graft or myocutaneus flaps. Each case was assessed for intraoperative, perioperative, and postoperative complications at the primary site of reconstruction. Patients were also evaluated for their ability to maintain an oral diet. Patients were followed up for a minimum of 2 months after surgery. Twentyseven patients aged 32 to 70 years (mean 51 years) underwent a syntetic esophageal reconstruction after total laryngopharyngectomy.Thirty patients had received postoperative external beam irradiation,. There were fiveteen fistulae and five with other complications. Ten patient died 3 months after surgery of distant or local metastatic disease. The oral realimentation can begin after 14 days. The ideal procedure is one which is safe, simple to execute, quick, carries a low complication rate and provides results comparable to more extensive procedure. The esophageal prosthesis offers a safe method of reconstructing the pharyngoesophageal segment, with an early oral realimentation, with a low rate of major complication and low cost.

A259 Possible alternative therapies to chronic laryngitis and laryngeal cancer: the use of COX-2 specific inhibitors M. Lima-Rodrigues*, A. Valle-Fernandes, N. Lamas, A. Vieira, R. Nunes, J. Pedrosa, A. Castro, F. Baltazar, R. Reis, A. Almeida Life and Health Sciences Research Institute, School of Health Sciences, University of Minho, Braga, Portugal; 2 Faculty of Medicine of Oporto, Porto, Portugal Treatment of chronic laryngitis is still unsatisfactory since corticosteroids and non-selective anti-inflammatory drugs are known to have adverse side effects. Although selective Cyclooxygenase-2 (COX-2) inhibitors have fewer side effects in the respiratory and gastrointestinal systems, no studies have analysed COX-2 expression in chronic laryngeal inflammation. Recently, it has been established a correlation between COX-2 expression, chronic inflammation and cancer in many tissues but, again, no studies have been performed in the larynx.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Nasogastric intubation (NGI) was used as a model to induce chronic laryngeal inflammation and the effect of a selective COX-2 inhibitor (Eterocoxib) was tested in the rat. The expression of inflammatory mediators and tumoral markers SP, CGRP, TNF-a, COX-2 and p16 was evaluated in the laryngeal mucosa after 1 and 2 weeks of treatment. We observed a depletion of laryngeal epithelial SP and CGRP fibers. In contrast, there was an overexpression of COX-2, TNF-a and p16 induced by NGI, together with an increase in mucosal mononuclear cells, glandular hypertrophy and hyperplasia with luminal enlargement. Treatment with Etoricoxib attenuated COX-2 and p16 expression and significantly decreased TNF-a levels. NGI induces a chronic neurogenic laryngeal inflammation through the release of neuropeptides SP and CGRP by laryngeal sensitive fibers. Simultaneously, other inflammatory and tumoral markers were overexpressed, suggesting a possible preneoplasic transformation. The attenuation of chronic laryngitis induced by the selective COX-2 inhibitor indicates that these drugs can be explored as a future alternative in the treatment of chronic laryngitis and, possibly, in the chemoprevention of laryngeal cancer.

A260 Posterior laryngeal clefts of late diagnostic S. Santos1*, L. Sgambatti2*, M. Dominguez1*, E. de la O3*, A. Bueno1, A. Suarez1 1 Hospital Nin˜o Jesus, Madrid, Spain; 2Hospital Clinico Universitario de Salamanca, Salamanca, Spain; 3Complejo Hospitalario de Caceres, Ca´ceres, Spain Objective: Describe two cases of posterior laryngeal clefts, have been reported as exceptionally rare congenital anomalies. classified by multiple different schemes. Type IA (Armitage) and type I (Benjamin and Inglis) laryngeal clefts exhibit absence or hypoplasia of the interarytenoid muscles with an intact cricoid rings. Submucous or ‘occult’ clefts occur with intact mucosa but absent underlying cartilage and/or muscle. Unless severe, they are seldom identified by radiographic studies and are only seen at rigid endoscopy when appropriate palpation of the posterior larynx is performed. That usually present with a history of recurrent respiratory tract infections during the early neonatal period. Methods/results: We report two cases in children and show the images with late diagnostic of a type I laryngeal cleft presenting with a history of recurrent lower respiratory tract infections and severe gastro-esophageal reflux disease. Conclusion: Presentation of type I clefts can be subtle and subsequently can result in late diagnosis and unnecessary complications.

A261 Postintubation laryngeal stenosis in children L. Zawadzka-Glos*, M. Jesionowska-Jablonska Department of Paediatric ENT, Medical University of Warsaw, Warsaw, Poland Subglottic laryngeal stenosis develops in most cases as a result of prolonged intubation. A lot of methods for treatment of postintubation stenosis are known, both classic methods for reconstruction of the larynx through an external approach, and endoscopic methods for dilation of the larynx. The selection of the method of tretment depends on the degree of stenosis and the kind of operations

1109 performed earlier. The authors present their own method for the treatment of postintubation laryngeal stenosis by argon plasma coagulation.

A262 Primary laryngeal non-Hodgkin’s lymphoma: case report I. Bartku*, I. Elek, E. Fu¨le, I. Fu¨lo¨p Department of Otorhinolaryngology Head and Neck Surgery, Nyiregyha´za, Hungary Objective: Lymphomas of the head and neck region are quite common, but non-Hodgkin’s lymphoma of the larynx is a rare entity. This study reports a case with primary laryngeal B-cell lymphoma. Method: Describing this case, clinical signs, diagnostic approach, staging, differential diagnosis, therapy, and prognosis are discussed, with a review of literature. Results: We present a 64-year-old woman with hoarseness and dyspnea. Performing a microlaryngoscopy and biopsy, the histopathology showed marginal zone B-cell lymphoma of the supraglottic area. After an examination we have found no systemic involvement. The patient underwent a laser surgery, and chemotherapy, a complete remission was obtained. After a 2-year follow-up no recurrence has been observed. Conclusions: Extranodal manifestation of the non-Hodgkin’s lymphoma in the larynx is exceptional rare. The diagnosis is made by direct laryngoscopy and biopsy. Our therapeutic choice was surgical intervention and chemotherapy.

A263 Recurrent laryngeal nerve paralysis after surgical closure of PDA in extremely low birth weight children H. Clemm*, L. Sandvik, O. Røksund, M. Hilland, J. Heimdal, J. Olofsson, L. Segadal T. Halvorsen Department of Oto-Rhino-Laryngology/Head and Neck Surgery, Heart Surgery and Paediatrics, Haukeland University Hospital, Bergen, Norway Introduction: There is an established association between persistent ductus arteriosus (PDA) in extremely low birth weight (ELBW) infants and a subsequent left-sided vocal fold paralysis (VFP). The objectives of this study were to assess the incidence of VFP and associated longterm morbidities in adult ELBW long-term survivors with a history of neonatal surgical closure of a PDA. Subjects and methods: All subjects born at a gestational age 28 weeks or with birth weight 1,000 g within a defined area in Western Norway in 1982–1985 were invited to a follow-up study and 46 (90%) of 51 eligible subjects responded positively. Twelve subjects had a history of neonatal surgical closure of a PDA, exclusions of four patients was necessary due to severe co-morbidity, the remaining 8 patients (66%) underwent transnasal flexible laryngoscopy with assessment of vocal cord motion and position of supraglottic structures. All these subjects performed a maximum exercise treadmill test. Results: Six out of 8 subjects (75%) had left-sided VFP. When questioned for symptoms, most affected patients reported shortness of

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1110 breath during exercise. During treadmill exercise testing, one patient developed cyanosis, while the remaining five patients seemed to be ventilatory limited as they all stopped the test before reaching their predicted maximum heart rate. Obvious stridor was observed in one patient only, the remaining five subjects had prolonged inspirium. Conclusion: Left sided VFP after PDA surgery in infancy is common in adult ELBW long-term survivors and is associated with respiratory symptoms, affecting voice as well as daily life physical activity. Symptoms are often not recognised and may be confused with other conditions such as bronchial asthma. References 1. Clement WA, El-Hakim H, Phillipos EZ, Cote´ JJ (2008) Unilateral vocal cord paralysis following patent ductus arteriosus ligation in extremely low-birth-weight infants. Arch Otolaryngol Head Neck Surg 134(1):28–33 2. Pereira KD, Webb BD, Blakely ML, Cox CS Jr, Lally KP (2006)Sequelae of recurrent laryngeal nerve injury after patent ductus arteriosus ligation. Int J Pediatr Otorhinolaryngol 70(9):1609–12 3. Zbar RI, Chen AH, Behrendt DM, Bell EF, Smith RJ (1996) Incidence of vocal fold paralysis in infants undergoing ligation of patent ductus arteriosus. Ann Thorac Surg 61(3):814–816

A264 Results of extended supraglottic laryngectomies Z. Petrovic1*, V. Nesic1, D. Radaljac1 Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre of Serbia, Belgrade, Serbia; 2ENT Department, Hospital ‘‘Dr. M. Marin’’’, Loznica, Serbia Classical indications for supraglottic partial horizontal laryngectomy are tumors of the laryngeal surface of epiglottis having spread to the anterior third of ventricular folds. Extended supraglottic partial horizontal laryngectomy may be performed in case of supraglottic tumors spread to valleculae and posteror third of the base of tongue as well as tumors infiltrating the upper medial wall of piriform sinus. Methods: This is a retrospective analysis of 522 patients with supraglottic laryngeal cancer primarily treated by surgery using the method of supraglottic laryngectomy in the period 1976–2002. The objective of the study was to analyze the success of the extended supraglottic laryngectomy in relation to classical supraglottic laryngectomy in indicated cases. Results: Classical supraglottic laryngectomy was performed in 454 patients, while 68 underwent extended supraglottic laryngectomy. T1 tumor was found in 219 (42%) patients, T2 in 272 (52%), while T3 was found in 31 (6%) cases. Local recurrence developed in 4 out of 68 patients operated by the extended supraglottic laryngectomy technique, and in 22 out of 454 operated by classical supraglottic laryngectomy (v2 = 0.134, DF = 1, P = 0.714; Yates = 0.005, P = 0.946). Five-year survival of patients operated by the extended supraglottic laryngectomy was reported in 51 out of 68 patients, while survival of patients operated by classical supraglottic laryngectomy was noted in 345 out of 454 cases (v2 = 0.032, DF = 1, P = 0.859; Yates = 0.001, P = 0.979). Conclusion: There was no significant difference of local recurrence and five-year survival between patients treated by classical and extended supraglottic laryngectomy. Keywords: Supraglottic carcinoma, Standard supraglottic laryngectomy, Extended supraglottic laryngectomy, Treatment outcome.

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A265 Sensitivity and responsiveness of the Medical Research Council Dyspnoea Scale to the presence and treatment of adult laryngotracheal stenosis R. Nouraei1,2*, M. Nouraei3, P. Randhawa2, J. Magill1, C. Butler1, D. Howard1, G. Sandhu1 1 Charing Cross Hospital, London, UK; 2The Royal National Throat Nose and Ear Hospital, London, UK; 3 University of Mazandaran School of Medical Sciences, Sari, Iran Objectives: To assess the sensitivity and responsiveness of the Medical Research Council (MRC) scale, a psychophysical dyspnoea assessment instrument to the presence and treatment of adult laryngotracheal stenosis. Design: Prospective observational study. Settings: Tertiary/National referral airway reconstruction centre. Participants: Forty tracheostomy-free patients undergoing endoscopic airway examination/laryngotracheoplasty. Main outcome measures: Demographic and clinical information, obtained from patient records, lesion severity, which was recorded intraoperatively, standard spirometry, which was measured preoperatively, and the MRC dyspnoea scale, which was administered preoperatively and at the first outpatient visit 4–6 weeks later. Results: There were 16 males and 24 females. Mean age at presentation was 44 ± 14 years (±SD). Postintubation stenosis was the commonest aetiology (73%) followed by idiopathic subglottic stenosis and Wegener’s granulomatosis. Six patients were examined post-treatment and had minimal residual stenosis and the remaining patients had glottic stenosis (n = 11) or Myer-Cotton Grade I (n = 8), II (n = 7) or III (n = 8) tracheal stenoses. Pre-treatment MRC dyspnoea scores and the degree of change in the MRC score following treatment strongly correlated with pre-treatment stenosis severity (r = 0.75 and r = -0.71 respectively; P \ 0.001). Moreover statistically significant correlations existed between preoperative peak expiratory flow and forced expiratory volume in 1 s and preoperative MRC dyspnoea scores (r = -0.34 and r = -0.35 respectively; P \ 0.05). Discussion: Exertional dyspnoea is the hallmark symptom of laryngotracheal stenosis and for many patients it is the primary cause of disability. These findings confirm that the MRC dyspnoea scale is an appropriate outcome instrument for assessing dyspnoea associated with this condition.

A266 Swallowing assessment in normal individuals with EMG, pharyngeal manometry and tongue pressure bulbs S. Vyas*, S. Gollins, H. Zeitoun Glan Clwyd Hospital, Rhyl, North Wales Objectives: To assess the normal swallowing mechanism using EMG, pharyngeal manometry and tongue pressure bulbs in healthy individuals. This is to establish a reference baseline level, in order to assess and treat patients with genuine swallowing difficulties/dysphagia. Methods: Using the swallowing workstation (SWS), which is a computerised machine, the EMG, pharyngeal manometry (PM), and

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 tongue pressure (TP) measurements were recorded. The EMG is performed by appling sticky pads to the submandibular area, to record the electrical impulses generated by the appropriate neck muscles. A 2 mm diameter manometer is passed through the nostrils and measurements were taken in the pharynx at the level of the base of tongue, hypopharynx, and upper oesophageal sphincter level. The tongue pressures are measured by a ‘tongue array’ which has tiny balloons for recording. The device is held in the mouth between the tongue and the roof of the mouth. Various manoeuvres are performed to assess the strength of the tongue muscles. With regards to EMG and PM, volunteers are asked to swallow several times, various quantities of water. Results: This study of EMG, pharyngeal manometry, and tongue pressure recordings in normal individuals will be of great benefit for further research into swallowing difficulties/dysphagia of head and neck cancer patients, either treated with surgery and or radiotherapy. In fact it can be beneficial in understanding other forms of dysphagia as well, such as globus or neurological aetiology.

A267 System for measurement of vocal fold polyps’ and glottal gap dimensions M. Kaseta1*, V. Uloza1, R. Pribuisiene¨1, V. Saferis2, V. Jokuzis3, A. Gelzinis4, M. Bacauskiene4 1 Department Otolaryngology, Kaunas University of Medicine, Kaunas, Lithuania; 2Department of Physics, Mathematics and Biophysics, Kaunas University of Medicine, Kaunas, Lithuania; 3UAB Elinta, Kaunas, Lithuania; 4Department of Applied Electronics, Kaunas University of Technology, Kaunas, Lithuania Objectives: The purpose of this study was to quantify the size of vocal fold polyps, and to investigate the relationship between the glottal gap and parameters of acoustic voice analysis and phonetography. Materials and methods: Eighty-one microlaryngoscopic images and digital recordings of sustained vowel [a] acquired from the patients with VFP were employed in this study. Vocal fold images were collected during routine direct microlaryngoscopy. Digital samples of sustained vowel [a] were recorded in a soundproof booth on a digitized Sony Mini Disc recorder MDS-101. Acoustic voice parameters and Phonetograms were analyzed using Dr.Speech (Tiger Elemetrics) software. Microlaryngoscopic images were processed by ELINTA software. The relative length and width of VFP were calculated in pixels, and the areas of VFP and glottal gap were calculated in square pixels, respectively. Results: A statistically significant slight correlation between relative dimensions of VFP and jitter was revealed. However, a statistically significant moderate negative correlation was found among the ratio of VFP and glottal gap areas and the normalized noise energy and harmonics to noise ratio. A mild positive correlation between ratio of VFP and glottal gap areas and some Phonetogram parameters was established. This study is still ongoing and recent results will be presented. Conclusion: Results of our study verify that quantitative microlaryngoscopic measurements of VFP and glottal gap maybe a useful tool for objective assessment of glottic incompetence and voice impairment. This study was supported by COST Action 2103 ‘‘Advanced Voice Assessment’’.

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A268 The influence of nasal pathology on nasality in speech I. Borsos, I. Hocevar-Boltezar*, C. Iglic, J. Urbancic University Department of ORL and HNS Ljubljana, Ljubljana, Slovenia Background: Nasal resonance in speech depends upon the velopharyngeal closure and normal patency of the nasal cavities. Incomplete velopharyngeal closure causes excessive nasal resonance in speech. In the case of the nasal pathology which narrows nasal cavities hyponasality is detected. The purpose of the study was to state the influence of deviation of nasal septum (DNS) on nasality in speech. Methods: In seventeen patients (11 M, 6 F) a subjective and objective assessment of nasality was performed before and 3 weeks after the surgery of DNS. The measurements were compared to the results of 10 control subjects without nasal pathology. Nasality was measured in 6 different tests (/a/, /m/, /pa/, /ma/, oral text, nasal text) by means of Nasometer (Kay Pentax, USA). The patients also assessed the influence of hyponasality on the intelligibility of their speech and their quality of life. Results: Nine patients noticed hyponasality in their speech before the surgery; three of them thought that their speech decreased their quality of life. After the surgery, the subjective and objective assessment of nasality showed improvement. A significant difference was noticed in the test /ma/. The nasality of the patients differed significantly from the controls especially in the vowel /a/. Conclusions: The results of the study showed, that hyponasality in speech often represents a problem for patients who have impaired nasal breathing due to DSN. The measuring of nasality can be used for objective indirect assessment of the results of the septum surgery.

A269 The model of examination of voice professionals and nonprofessionals with voice disorder E. Osipenko1*, A. Dgagaeva2* 1 Federal Research Clinical Centre of Otorhinolaryngology, The Ministry of Public Health, The Russian Federation, Moscow, Russia; 2Dubninsky City Hospital, Moscow, Russia Introduction: The examination of the patients with voice disorder widely varies in different clinics. The diagnostic model allowing to define the correct, effective and complete diagnosis in the each case of voice disorder has been developed in the laboratory of singing and scenic voice and consists the three obligatory steps; 1. Preparation of the history of voice disorder, including the exhaustive anamnesis collection; 2. Objective visualization of the larynx and other interesting us organs (videostrobolaryngoscopy, flexible fiberopticlaryngoscopy, mikrolaringoskopy); 3. The estimation of the acoustic parameteres of the spoken and vocal voice, electroglottography with the help of MDVP. In future depending on professional factor and\or presence of concomitant etiologic diseases it is necessary to carry out the speech and vocal tests with voice loading; the aerodynamic researches, the definition of the psychological condition, the daily 24-h pH-monitoring, the electromyography, the definition of the coefficient of the accommodation.

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1112 Conclusion: A.

The given diagnostic model should be used for 1) nonprofessionals of the voice in case of the voice changes defined orally, in case of complaints about hoarseness, fatigability, a ‘weak’, ‘high’, ‘low’ voice; 2) nonprofessionals of the voice, in case of the absence of changes defined orally, in case of getting new job, and for actors and vocalists entering the institutes. B. The obligatory regular medical check-up among people using their voices professionally.

A270 The normal development of voice in children: phonetographic aspects M. Fog Pedersen1* 1 Copenhagen, Denmark Introduction: The phonetographic measurements of children seem to be a help in placing them in choirs. But also in pathology, it is of value to be able to compare phonetograms to normal children of the same age. Material: 48 voice-trained boys and 47 voice-trained girls in a school choir were examined in a stratified study, 4-5 children on each grade. Methods: Phonetograms were made after the standard suggestion by the European Union of Phoniatricians. Averages and standard deviations for each grade were made in a computer programme constructed by the firm ‘Voice profile’. Results: For each year during development of voice, the phonetograms and averages are presented: lowest and highest tones as well as maximum dynamic range, and area calculations. An Introduction is made to our computerized phonetogram. Discussion: In COST 2103 of Advanced Voice Assessment, a scientific study in the European Union, it is suggested that a standard for measurements of frequencies in the phonetograms are made. The measurements in our study were made manually. The averages and standard deviation in our computer programme is based on phonetography registered by a computer. This is also a reason for discussing the market of phonetography.

A271 The nutritional management of the patients with head and neck cancer S. Bertesteanu1*, G. Raluca1, D. Mirea2, D. Ionescu3, C. Popescu1 1 Head and Neck Surgery Department, Coltea Clinical Hospital, Bucharest, Romania; 2ENT Department Euroclinic Hospital Bucharest, Bucharest, Romania; 3 University Clinical Hospital, Bucharest, Romania The enteral and/or parenteral clinical nutrition is an important part of the complex multidisciplinary treatment of the patients with head and neck cancer. A particularity of these patients is, besides the neoplasic cachexia, the presence of the mechanic cause of malnutrition. The authors present the therapeutic protocol of Coltea Head and Neck Surgery Clinic for the patients with cervicofacial cancer. The moment and ways of administration depends on neoplasic stage (TNM), risk and grade of malnutrition, surgical and chimoradiotherapic treatment. If we put in practice the principles of clinical nutrition do not have a

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 significantly impact of the surviving rate, but if ignore the nutritional status worsens the overall outcome.

A272 The vocal organ assessement in young patients with anorexia nervosa: preliminary reports B. Wiskirska-Woznica1*, Maciejewska1, A. Obreˆbowski1, A. Rajewska-Rager2, A. Rajewski2 1 Department of Phoniatrics and Audiology, Univerisity of Medical Sciences of Poznan˜, Poznan˜, Poland; 2Department of Children and Youth Psychiatry, Univerisity of Medical Sciences of Poznan˜, Poznan˜, Poland Anorexia nervosa impairs functions of most systems and internal organs. Significant hormonal disorders are observed. It has been proven that anorexia nervosa affects the hypothalamus–pituitary– gonads axis and pubescence. The objective of the study was assessment of vocal organ in girls treated for anorexia nervosa, with regard to possible impact of significant decrease in body weight, abnormal breathing, menstruation disorders and emotional problems accompanying anorexia on the phonation function of larynx. Materials and methods: 20 girls in the age of 12–19 were involved in the study, with diagnosed anorexia, with which a complex assessment of vocal organ was performed (perceptual voice assessment in GRBAS scale, videolaryngostroboscopy, acoustic analysis and voice self-assessment in VHI scale. Results: In 85% of our patients during a routine laryngological examination lack or weakening of pharynx reflexes was noticed. All patients displayed breathing irregularities. 85% had significantly shortened maximum phonation time, proportionally to the duration of underlying condition. Videolaryngostroboscopy examination revealed voice disorders of functional character in 50%, confirmed during acoustic analysis. Among older patients, past pubescence, in 42% of cases larynx structure inappropriate for their age. Observed structural and functional changes of vocal organ in anorexia nervosa indicate involvement in phoniatric care of a group of patients with eating disorders of psychological background. Results of the study suggest paying attention to earlier involvement in the therapeutic process of hormonal substitution in patients in pubescence period, due to which growth and phonation function of larynx may approach physiological characteristics.

A273 Use electrical neuromuscular stimulation of the larynx at during hypofunctional dysphonia E. Osipenko*, N. Daikhes, I. Mihalevsky, Z. Agaronova Federal Research Clinical Centre of Otorhinolaryngology, The Ministry of Public Health, The Russian Federation, Moscow, Russia Introduction: There are many various techniques of hypofunctional dysphonia (HD) treatment depending on the degree of glottis closure. In the conditions of the modern megalopolis it is necessary to find the way combining qualities of safety, efficiency and patient—short-time hospital stay. In our opinion, the most optimal treatment is the combination of physiotherapeutic and voice therapy exposure which is provided with electrical neuromuscular stimulation (ENMS) of the larynx in aggregate with medicamental therapy.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Methods: 250 patients suffering from HD have been treated. The disease was diagnosed on the basis of patients’ complaints, videostrobolaryngoscopy, research of the factor of neuro-muscular unit accommodation. The vocal function has been estimated before and after the course of treatment with the use of Multi-Dimensional Voice Program (MDVP). The complex therapy, besides the standard medicamental methods of treatment, has included ENMS with the use of device ‘VocaStim’ (10–15 procedures, daily, 30 min). Results: The number of complaints has been decreased even during the second procedure among 100% of patients. After the fourth procedure 62% of patients has noticed the substantial improvement in the force and sonority of the voice, also it became more endurable. These were proved by the MDVP test indicators, and also clinical data. After the course termination all showed the improvement of a phonation and of valvate larynx mechanism. Conclusion: The restoration of the initial state and the maintenance of the muscle tone of the vocal apparatus with ENMS show its efficiency in the complex therapy of HD.

A274 Voice assessment after endoscopic laser cordectomy: a prospective study L. Crevier-Buchman1,2*, S. Hans1, M. Menard1, D. Brasnu1 1 Hoˆpital Europe´en Georges Pompidou, Paris, France; 2 CNRS LPP-UMR 7018, Paris, France Objectives: Endoscopic laser cordectomy is a minimally invasive surgical technique for T1 glottic carcinoma. The purpose of the study was to evaluate prospectively before and 6 months after surgery i) acoustic and perceptual parameters, ii) quality of life through a self evaluation (VHI) test. Methods: This longitudinal study aims to assess voice in 16 male patients, recorded before and at 1, 3 and 6 months after surgery. Acoustic parameters (F0, Jitter, Shimmer, Maximal and Minimal F0 and Intensity parameters) were recorded with MDVP and Voice Range Profile (Kay Elemetrics) as well as Maximum Phonation Time (MPT) and speech rate. Voices were perceptually evaluated using the GRBAS scale and the self evaluation was conducted with the Voice Handicap Index (VHI). Correlations between the different dimensions of voice assessment were measured. Results: Perceptual and self evaluation data had a favorable evolution between 1 and 6 months for all patients. Acoustic parameters improved less significantly especially for type V cordectomie. Conclusions: The quality of voice is a very important criterion for the patients. During the first 6 months after laser cordectomy, the perceptual vocal function and the self evaluation improved. The type of cordectomie will influence the evolution of acoustic and perceptual data but there is no correlation with self-evaluation.

A275 Voice rehabilitation with the use of voice prosthesis after total laryngectomy E. Beis*, A. Christoforidou, S. Triaridis, A. Nikolaou, V. Vital University ENT Department, AHEPA General Hospital of Thessaloniki, Thessaloniki, Greece

1113 Introduction: The use of voice prosthesis for voice restoration after total laryngectomy has become very popular over the last decades. Background: Complications however are quite common and induce the need for frequent valve replacement. Objective: To study the frequency of prosthesis replacement and analyse the indications. Patients and methods: 51 laryngectomised patients were included in a prospective study in the period from October 2006 to December 2008. Device lifetime, complications and the need for closure of the tracheo-oesophageal fistula were assessed. Results: The prosthesis lifetime varied from 1 to 26 months (mean 10.4 months). The number of valve replacements needed in each patient varied from 0 to 7 (mean 2.8). Leakage through the device was the most common complication (88,75% of the replacements). Other indications were: granuloma (4.95%), leakage around the prosthesis (3.5%), inflammation (0.7%), fungal infection resistant to therapy (0.7%) and rejection of the valve (0.7%). Definitive closure of the tracheo-oesophageal puncture was necessary in 5 patients. Conclusion: The most frequent complication of the use of voice prosthesis is the leakage through the device that is caused by the fast wear and tear of the materials used for its manufacture. OTOLOGY

A276 10 facts an ENT physician should know about ear wax M. Schwaab*, S. Hansen, A. Gurr, A. Minovi, S. Dazert Departement of ENT, Head and Neck Surgery, RuhrUniversity Bochum, Bochum, Germany An acute hearing loss caused by obstructing ear wax is a common problem leading patients to an ENT department. Ear wax is often regarded as needless because of our missing knowledge about it. Though the knowledge about the function and historical use of ear wax is relatively unknown. Materials and methods: We therefore want to close the gap in one0 s knowledge by summarizing the common literature (PubMed research, Google) and our own data about a misconceived but very interesting human product.

A277 Three cases of the binaural cochlear implantation: future method of choice? M. Kisiel2*, M. Steczen2, R. Chmielewski1*, K. Niemczyk1 1 ENT Department, Warsaw Medical University, Warsaw, Poland; 2Warsaw Medical University, Warsaw, Poland Concepts of bilateral cochlear implantation raised in late 1980s. It was advised for children without satisfying results after the first surgery. Nowadays bilateral implantation is the method which is widely accepted for all candidates for cochlear implantation. Limitations for bilateral implantation include financing of the procedure and a fear about the condition of both ears for next implants generations. The special solution for patients and countries where reimbursement did not covert two implants was invented by Truy et al. (2003). This cochlear implant with 24 channels comprises two

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1114 active electrodes (each electrodes has 12 channels) and one internal processor. The authors presented results of 3 binaural implantations in different clinical situations: post-meningitis, obliteration due to cochlear otosclerosis, and posttraumatic. Special surgical technique which involves bilateral approach for the cochlea and subperiosteal passage of the long electrode around the skull. All patients were evaluated using the following tests: free field—threshold evaluation, vocal audiometry in silence an noise, a battery of speech perception evaluation tests and sound localization tests. Analysis of the tests revealed that bilateral stimulation induced better speech perception in silence and especially in noise. With binaural stimulation it was also possible to achieve some sound localization with improved quality of live. Binaural implantation is an efficient solution in cases when both ears need to be supplied with cochlear implants. Binaural stimulation by one receiver provides simultaneous stimulation to both cochleae improving speech perception results. Localization tests indicate that it is possible to achieve some sound spatial recognition.

A278 A case of late labyrinthic complication after mastoidectomy with tympanoplasty for chronic cholesteatomatous middle-ear suppuration E. Anghel, J. Becherescu* Institute of Phonoaudiology and ENT Surgery ‘‘Prof. Dr. Hociota’’, Bucharest, Romania Mastoidectomy is considered the main treatment of the infectious process in chronic middle-ear and mastoid suppurations. Tympan and middle-ear bone complex damage due to infection and cholesteatoma leads to total or partial removal of this complex. Tympanoplasty could be performed eventually as second intervention, in the absence of suppurative or cholesteatomatous recurrence. We present the case of a 34-year-old male, admitted 11 years ago in a different clinic with left chronic suppurative polypoid and cholesteatomatous otomastoiditis, for which he underwent left partial tympanic and mastoid evidement with consecutive tympanoplasty. He was admitted 9 month ago in our clinic with polypoid and cholesteatomatous recurrence in the evidement cavity, extended in the internal ear. We performed left total tympanic and mastoid evidement with interposition of temporal fascia graft on both vestibular and cochlear ramps. The graft was applied using organic adhesive. Patient’s evolution was very good, with complete graft integration and no infectious or cholesteatomatous recurrence. Performing mastoidectomy with tympanoplasty in patients with chronic suppurative polypoid and cholesteatomatous process of the middle-ear is risky. It could be tempted only after a period of time, which is necessary to confirm the absence of suppurative recurrence. Keywords: Tympanoplasty, Mastoidectomy, Cholesteatoma.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 The measurement of otoacoustic emissions (OAE) has been used in the diagnostic assessment of patients with tinnitus. Aim: The aim of the study was to determine the characteristics of DPOAE in tinnitus and non tinnitus ears in two groups of tinnitus subjects with normal hearing and with hearing loss. Method: We obtained DPOAEs from 227 tinnitus ears and 93 non tinnitus ears of 160 patients with tinnitus and hearing loss, 225 tinnitus ears and 75 non tinnitus ears of 150 patients with tinnitus and normal hearing and from 40 ears of 20 subjects with normal hearing, without tinnitus (normal group). In order to determine the influence of hearing loss on the DPOAE amplitude we divided the group of patients with hearing loss in two subgroups, those with high frequency hearing loss and those with notched hearing loss. In order to determine the influence of aging on the DPOAE amplitude we divided the patients in two age groups \50 years and [50 years. Results: In patients with tinnitus and hearing loss the DPOAE amplitude was reduced in the high frequencies with hearing threshold \30 dB. In normal hearing patients with tinnitus DPOAE with abnormally reduced amplitude were obtained from 179 out of 225 tinnitus ears (81%) and from 25 out of 75 non tinnitus ears (32%). Conclusion: The high percentage of abnormal DPOAEs in tinnitus patients with clinically normal pure-tone hearing thresholds has important diagnostic implication, by documenting abnormal cochlear function in a frequency region corresponding to their perceived tinnitus.

A280 About unilateral otosclerosis A. Antohi*, S. Vetricean, J. Antohi, E. Cernolev, A. Bajureanu, C. Eremia Department of Otolaryngology, Central Hospital, Kishinev, Republic of Moldova Objective: To study a cases of unilateral otsclerosis treated at our clinic between 1998 and 2008. Materials and methods: From 17 patients—13 were female and 4-male aged of 24–56 years old. The diseases lasting more that 7 years. In 7 cases was damaged right ear, in 10-left. All has accuzed an unilateral hearing loss. We used otoscopy,otomycroscopy, fork tests, audiometry, impedancemetry. The media of air-bone gap was 25–30 dB. In 14 cases was performed stapedoplasty (8 stapedotomies-House method and 5 stapedectomies-Shea method). Four patients refused surgery. Outcomes: All patient after surgery has a vertigo syndrome. A facial palsy signs were not found. The media of air-bone gap was 10–15 dB. Conclusions: In spite of goodknowm thing that otsclerosis affects both of ears, we have been meetihg an unilateral process.

A279 A study of DPOAE in patients with tinnitus

A281 Active middle ear implant vibrant soundbridge in sensorineural hearing loss

D. Psifidis*, V. Nikolaidis, A. Psifidis, C. Themelis, S. Metaxas ENT Departments, Aristotle University of Thessaloniki, Thessaloniki, Greece

K. Boeheim*, S. Pok, M. Schloegel ENT-Department, Landesklinikum St. Poelten, St. Poelten, Austria

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Introduction: Despite continuous technical improvement, hearing aids are helpful to only some patients with sensorineural hearing loss (SNHL). This is especially true for patients with high frequency hearing loss, since it is difficult to provide sufficient amplification without risk of feedback and distortion in the high frequencies. In addition the benefit of the amplification may be overshadowed by the problems of the occlusion effect. In contrast to conventional hearing aids, in active middle ear implants (AMEI) the amplified sound signal is transmitted as vibrational energy directly onto the ossicles while bypassing the external ear canal. Methods: An audiological evaluation of 54 recipients of a Vibrant Soundbridge (VSB) was performed. We assessed the subject’s preand postoperative hearing thresholds (0.25 to 8 kHz), calculated the functional gain with the VSB and compared it with their hearing aid (HA). In addition unaided and aided speech discrimination scores were assessed. A special focus was directed on the impact of AMEI on ski-slope high frequency hearing loss. Furthermore statistical correlation coefficient analysis was performed to assess potential predicting factors—‘age at implantation’ and ‘pure tone averages’—that might have an impact on postoperative benefit. In addition we compared rehabilitation with AMEI to open fitted hearing aid in a group of patients with SNHL with overlapping audiological indication fields for both devices. Results: In SNHL, functional gain was in proportion to the individual hearing losses and was remarkably high over the whole frequency range from 0.25 up to 8 kHz. Especially in the high frequencies a high functional gain was achieved. Monosyllabic word discrimination was better in both aided conditions compared to the unaided condition. In the VSB-aided condition significantly higher speech recognition scores were observed compared to the HA-aided condition. The factor ‘pure tone averages’ correlated with monosyllabic word recognition scores, while no correlation was found with the factor ‘age at implantation’. In the comparative study of AMEI versus open fitted hearing aid, a significant difference was observed in favour of AMEI (functional gain, speech discrimination in quiet and noise). Conclusion: In SNHL and particularly in high frequency hearing loss the VSB-system provides the desired amplification according to the patient’s needs across the whole frequency range up to 8 kHz. In our subjects a significant improvement of speech recognition scores was found compared to the unaided and the HA -aided test conditions, respectively. By following the recommended indication field for the VSB-system, we consider this device as an effective treatment option in SNHL with unsatisfying benefit from conventional hearing aids.

A282 Adult xanthogranuloma of the external auditory canal H. Iguchi1*, Y. Haruta1, T. Wada1, H. Amatsu1, H. Yamane1, K. Wakasa2 1 Department of Otolaryngology and Head and Neck Surgery, Graduate School of Medicine, Osaka City University, Osaka, Japan; 2Department of Diagnostic Pathology, Graduate School of Medicine, Osaka City University, Osaka, Japan Xanthogranuloma is the most common form of non-Langerhans cell histiocytosis, and generally exhibits benign clinical behavior. Although it predominantly arises from the skin of the head and neck

1115 region in infants, approximately 15% of cases appear in adults, most commonly in the 20s and 30s. It is extremely rare for xanthogranuloma to arise from the external ear, especially from the external auditory canal. We present a case of adult xanthogranuloma that originated in the anterior wall of the external auditory pore of a 57year-old Japanese man. He visited our clinic complaining of a 2-year history of a non-tender mass in the opening of the left external auditory canal. He denied hearing impairment in the affected ear. There was no history of trauma of his left ear. Physical examination revealed a yellowish-brown and well-defined papule measuring 7 mm in diameter in the anterior wall of the left external auditory pore. Systemic examination was normal. Laboratory examination revealed no evidence of hyperlipidemia. The mass was completely excised under local anesthesia. Postoperative pathologic examination revealed diffuse proliferation of foamy histiocytic cells with eosinophilic cytoplasm, admixed with lymphocytes, eosinophils and multinucleated Touton giant cells. Immunohistochemically, these histiocytic cells were positive for a macrophage marker CD68, and negative for the neural marker S-100 protein. These pathologic findings confirmed the diagnosis of xanthogranuloma. He has been doing well for 5 years after surgery. He is the oldest patient with external auditory canal xanthogranuloma among cases in the English literature.

A283 An audiological case study of progressive hearing loss associated with distal renal tubular acidosis M. Ioannou1, A. Aspris1, I. Kyamides1

Withdrawn

A284 Anatomical variations and anomalies of the facial nerve seen in the middle ear during stapes surgery M. Hainarosie*, G. Georgescu, R. Udrescu IFACF-ORL, Bucharest, Romania The existence of course abnormalities of the facial nerve at the level of tympanic segment increases the risk of nerve injuries during middle ear surgery. In this retrospective study we present the anatomical variations and anomalies of the tympanic segment of the facial nerve recorded during surgeries for otosclerosis from 1999 to 2008. We reviewed the chart of 2,384 stapes surgeries done in our hospital during the last 10 years. Data including bony dehiscence of the Fallopian canal, their dimensions and situation, the position of the facial nerve in relationship with oval window and with stapes crura, the anomalies of the nerve course were recorded. The results showed 21% bony dehiscence of the facial canal. Dehiscence bigger than 3 mm were encountered in 8% of cases, of which 71% in the oval niche area. Complete dehiscence was recorded in 4% of cases. A low situated facial nerve was encountered in 9% of cases among which in 2% the nerve touched the stapes crura. An anomalous nerve course which passed between stapes crura was seen in one case, representing 0.04%. Postoperatively no persistent facial paralysis was observed. The in-depth knowledge of anatomical variations and anomalies of the facial nerve course is essential in order to decrease the risk of

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1116 iatrogenic injuries during routine ear surgery. Our study shows an incidence of facial canal dehiscence statistically significant lower that the majority of studies reported.

A285 Anxiety and depressive symptoms in Meniere’s disease patients L. Nimroda1*, L. Kise1, M. Nimroda2 1 Paul Stradins Clinical University Hospital, Riga, Latvia; 2 Ministry of Children, Family and Integration Affairs of the Republic of Latvia, Riga, Latvia Introduction: Although Meniere’s disease is not regarded as life threatening, most patients consider the condition life altering. The sudden and unexpected attacks can cause a dramatic influence on the patient’s quality of life. Patients with Meniere’s disease may have greater emotional disability and physical disability. The aim of this study was to identify factors that may correlate with anxiety and depressive symptoms of Meniere’s disease. Materials and methods: A total of 31 patients (age range, 23– 77 years; mean age 47.48 years) suffering from definite Meniere’s disease diagnosed according to the 1995 guidelines of the American Academy of Otolaryngology-Head and Neck Surgery Commitee on Hearing and Equillibrium were examined and included in the study, which was performed at the Paul Stradins Clinical University Hospital ENT Clinic. The study was started in March, 2007. The patients were asked to fill out questionnaires: the Dizziness Handicap Inventory (DHI), the Hospital Anxiety and Depression Scale (HADS) and the Beck Depression Inventory (BDI). Results: There was correlation between the caloric responses and anxiety symptoms. DHI score is correlated to both anxiety and depressive symptoms (P \ 0.05); the same significance was found between HADS anxiety and both HADS depression score and BDI score as well as depression score between HADS and BDI. 70.97% have an anxiety disorder. 22.58% shows both anxiety and depressive pathology. Conclusions: Both anxiety and depressive symptoms are correlated to DHI as well they correlate between each other of Meniere’s disease patients. The caloric response is a predictor for patients with higher level of anxiety. Increasing patient’s age decreases anxiety.

A286 Assessment of hearing in children aged 2 to 18 months R. Dauman*, I. Gavilan-Cellie´ University of Bordeaux, CHU of Bordeaux, Bordeaux, France Purpose: (a) To analyze similarities and differences in methods for testing behavioral responses in candidates for pediatric cochlear implantation; (b) to investigate pre-operative audiometric results in hearing impaired children as a function of age and health-related issues during the first months of life. Methods: Prospective study of all hearing impaired children detected at birth since March 2005 in our region, in the framework of the AFDPHE project (French association for screening and prevention of pediatric handicaps).

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Results: Results in transferred neonates show the need for verifying stability of hearing before undergoing cochlear implantation during the first year of life. Follow-up of babies screened at birth also demonstrate that behavioral assessment of hearing is feasible and reliable.

A287 Audiological findings in children with cleft palate our experience in 74 cases L. Sgambatti1*, S. Santos2*, M. Dominguez2*, E. de la O3*, A. Bueno2, A. Suarez2 1 Hospital Clinico Universitario De Salamanca, Salamanca, Spain; 2Hospital Nino Jesus, Madrid, Spain; 3 Complejo Hospitalario de Caceres, Ca´ceres, Spain Background and objective: Hearing impairment is one of the associated problems seen particularly in children with cleft palate. Otitis media with effusion is known to be very common among children with cleft palate, however, less is known regarding the natural history and outcome in this group. The purpose of the present study was to examine the incidence, treatment, and outcome of middle ear disease in children with clefts palate. Study design: Descriptive and retrospective study in a pediatric tertiary care facility. Methods: A total of 74 cases (33 females, 41 males) of children’s with palatal cleft were identified with complete records, including clinical and otologic evaluation, hearing status was assessed using behavioral testing or auditory brainstem response (ABR). Results: Hearing loss was seen in 43 (58%) patients, conductive HL was seen in 39 (52%), mixed HL 2 (3%), sensorineural 2 (3%). Moderate HL was seen in 36 (48,6 %) all of them conductive. Severe HL in 6 (8%) 1 sensorineural,2 mixed, 3 conductive. Profound HL 1 (1,3%) sensorineural. We find associated syndromes to cleft palate, 16 Pierre Robin, 4 Stickler, 2 Treacher Collins. Conclusions: The conductive hearing loss in children with cleft palate is very frequent. There is a need for early identification and intervention of middle ear effusion for all cleft palate cases.

A288 Auditory neuropathy: clinical characteristics and therapeutic approach in 7 cases M. Dominguez1*, L. Sgambatti2*, S. Santos1*, E. de la O3*, A. Suarez1, A. Bueno1 1 Hospital Nin˜o Jesus, Madrid, Spain; 2Hospital Clinico Universitario de Salamanca, Salamanca, Spain; 3Complejo Hospitalario de Caceres, Ca´ceres, Spain Background/objective: Auditory neuropathy/dys-synchrony, characterized by absent auditory brainstem responses, normal otoacoustic emissions or cochlear microphonics, and word discrimination disproportional to the pure-tone audiogram and management strategies remain controversial. Study design: Retrospective and descriptive in pediatric tertiary care center.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Methods: 7 cases in children diagnosed with auditory neuropathy at our center from 1999 to 2007 were reviewed for background data, associated factors, audiometric findings, management, and outcome. Results: Mean age at diagnosis was 16 months. Factors known to be associated with AN were found in 7 children, prematurity and low birth weight, hyperbilirubinemia, parental consanguinity, or positive family history, were found 1 children with MELAS syndrome and 1 children with Pelizaeus Merzbacher disease. The hearing loss was mostly moderate to severe, and bilateral in all patients. Two patients received cochlear implants with good outcome. Conclusions: Auditory neuropathy is a disorder which presents with different clinical and audiological findings and its important accurate identification, based on subjective and objective hearing assessment techniques, and timely treatment of the affected children. Thus the management of this disorder must be an individual one.

A289 Bilateral middle ear osteomas: a case report D. Lefantzis, M. Artopoulos*, E. Chalidia, M. Charalabopoulou, C. Christidis, G. Papazoglou Korgialenio-Mpenakio (Red Cross) Hospital, Athens, Greece Osteomas of the middle ear are rare benign neoplasms. To date, 29 cases have been reported in the English literature. The most common symptom is conductive hearing loss. We describe a rare case of bilateral middle osteomas with unilateral symptomatology of hearing loss. The otoscopic examination of the right ear, with hearing loss, revealed a white mass protruding through the intact tympanic membrane. This mass gave a bony feeling in palpation with a cotton applacator. On the contralateral side, the audiogram showed normal hearing and on otoscopy a white shadow behind the ear drum was noticed. The CT revealed bilateral calcic density mass on the promontory. Under general anesthesia, the patient underwent right exploratory tympanotomy through endaural approach revealed a rock hard white bony mass originated from the promontory protruding towards the external auditory meatus, pushing the tympanic membrane like a tent outwards and made it thinner and almost impossible to be elevated intact. The osteoma was removed along with the adjacent thinned part of the tympanic membrane using a small diamond burr and the eardrum was restored with tympanoplasty using temporal fascia. Osteomas of the middle ear are usually small and tend to remain stable in size, periodic evaluation is preferable in patients without symptoms, because removal of middle ear osteomas is not without risk. However in patients with conductive hearing loss, vertigo, or eustachian tube obstruction, the suggested treatment is surgical exploration and judicious removal.

A290 Characteristics of auditory screening in infants M. Davidziuk*, E. Merkulova Department of Otolaryngology, Belarusian State Medical University, Minsk, Belarus In 2008 in Belarus the first screening program of infants’ hearing investigation was started. The aim of our study was to analyze the

1117 results of infant hearing screening in children’s polyclinic conditions. We examined 271 children at age of 1 month to 1 year. 223 (82.3%) children were 1 to 3 months of age, 48 (17.7%) were older than 3 months. The children underwent TEOAE, DPOAE and, if necessary, ABR registration. Polyclinic examination of infants suspected of hearing impairment has its characteristic features. The majority of children (82.3%) were 1 to 3 months of age. Repeated examination was necessary in 29 cases (10.7%) because of the following reasons: – restless behavior (14 children); – controversal results in 11 cases (two children twice invited to repeated visits); – acute otitis media 2 weeks before examination (1 child); – acute otitis media for the time of visit (1 child); – complete bilateral obstruction of external acoustic meatus with cerumen plugs (1 child). Most repeated visits were performed in winter, when the incidence of acute respiratory infections is high. Notable that 40 infants did not show up at scheduled primary audiologic visit. Organization of ambulatory infant hearing screening is difficult due to high percentage of children suffering from middle ear pathology on background of upper respiratory tracts inflammation as well as of parents’ underestimation of role of auditory function check on early stages of infants’ development. These facts demonstrate necessity of further study able to provide optimal algorithm of audiologic screening for infants.

A291 Chemodectomas of the glomus vagale P. Martinez-Seijas*, U. Bolinaga Zubizarreta, R. Lobato Perez, N. Perez Martin, J. Arruti Gonzalez Hospital Donostia, San Sebastia´n. Spain Introduction: We present a clinical case patient with a vagal chemodectoma. Materials and methods: We describe the clinical and radiological finding in a patient with a painless unilateral cervical round swelling. The clinical sings, arteriography (the tumour was embolization), and magnetic resonance present a locally round tumour in the carotid triangle. Diagnosis of vagal chemodectoma a surgical exploration we find the tumour into the right vagal nerve. The removal of the tumor with the vagal nerve affected. Histopathologic examinatio: chemodectoma of a vagal nerve. No recurrence occurs and the patient present a lesion of recurrent laringeal nerve. Discussion: The head and neck chemodectoma vagal tumours account for less than 5% of all paragangliomas and 10% multicentric. The most common initial finding was a neck mass that can mobilize medial to laterally but not cranial caudal. In some cases could have a vocal cord paralysis at presentation or in its evolution. Angiography is beneficial:tumour vascularity and possibility of tumour embolization. The surgical removal is the treatment choice. Conclusion: • • • • • •

Head and neck chemodectoma vagal tumour is a rare tumour. MRI explores the relationship of the tumour. FNA avoid as soon as possible and is mandatory a previous MRI. Angiography is useful to explore tumour vascularity and possibility of tumour embolization. Surgical remove is the treatment choice. In some cases the reconstruction with graft nerve could repair the vagal nerve.

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A292 Chronic otitis media with effusion tympanometric and audiometric correlations: our experience 1

2

R. Enache *, I. Voda 1 ENT Department Sfanta Maria Hoaspital, Bucharest, Romania; 2ENT Department Nova Clinic, Bucharest, Romania Otitis media with effusion is a common pathology found both in adult and child patients due to Eustachian tube dysfunction. All this patients need monitoring. The tonal audiogram and tympanogram have been commonly used for evaluation of otitis media. There are cases in which there is no correlation between audiometric, tympanometric and clinical aspects of the disease. The authors present their experience on a group of 253 patients with chronic otitis media with effusion during two years period. They evaluated the correlations between tympanometric and audiometric aspects. The results showed that in 26% of the cases there was no correlation between the tympanogram and tonal audiogram. These two investigations were made as a primary evaluation of the patient with otitis media with effusion and, than, as final evaluation after a month. In conclusion the diagnosis of otitis media with effusion should not be made only on tympanometric or audiometric aspects. If we use only the tympanogram we can obtain normal curves despite the presence of the effusion in the cavum tympani. The audiogram may show a normal hearing but with high depressurization which needs treatment and monitoring. So, the diagnosis and the evaluation should be made on tympanometric and audiometric aspects.

A293 Clinical-audiometric assessment of results of treatment of patients the mixed form hypoacusis at persons occupied in oil industry of Azerbaijan S. Goyushova*, F. Djavadov The Central Hospital of Oil Explorers, Baku, Azerbaijan We analyse 500 patients from 30 till 60 years with the mixed form of hypoacusis. The clinical picture was shown stuffiness in ears, hearing fall, ringing in the ears, in rare vertigo. The purpose of the present research: Carrying out of a comparative estimation of dynamics of clinical and audiometric indicators of hearing at the patients receiving treatment in ambulance condition and the rest at home condition. 250 patients have received treatment in ambulance condition the others at home. All patients received the standard basic treatment: vitamin therapy, the preparations improving brain blood circulation. From them 250 patients, who received treatment in ambulance conditions, received local treatment in a kind catheterization an Eustachian tube with the subsequent Introduction of preparations containing gyaluronic acid, endoaural elektoforesis about 4% a solution kalii jodidi (the basic group), others 250 received basic therapy in home conditions (control group). Results: 1.Clinical efficiency of local therapy in a kind catheterization an Eustachian tube at patients with the mixed form of hypoacusis (the basic group) above, than at control group. 2.Indicators of an audiometric picture at patients of the basic group it is better,than at patients of control group.

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A294 Cochlear implant in ENT Department Timisoara S. Cotulbea*, S. Horatiu, D. Virgilius, T. Delia, R. Andreea ENT Department Timisoara RO, Timisoara, Romania Objectives: This study reviews the therapeutical possibilities of patients with sensorineural hearing loss, emphasizing the advantages of cochlear and middle ear implant over conventional hearing aids. Methods: Patients with bilateral profound sensorineural hearing loss are completely evaluated audiologically, imagistically and neuropsychologically and the development of the speech is carefully assessed. As the indication of cochlear implant is established, the patient undergoes surgery, and the electrode array of the device is inserted in the cochlea, and the internal processor is embedded in the temporal bone. Four weeks later the external processor, which is behind the ear, is activated. Middle ear implant is indicated in less severe sensorineural hearing loss, and only for post lingual onset of the hearing loss. Results: In our clinic there were already made 52 cochlear implants. Conclusions: The use of hearing aids in moderate and severe neurosensorial hearing loss has proved to be satisfactory for the patient in only about 30–40%, which have determined the need for new therapeutical solutions.

A295 Cochlear implantation in treating sensorineural hearing loss due to inner ear malformations A. Gocea1*, P. Claros2,3, M. Claveria3, M. Cosgarea1 1 ENT Clinic Cluj-Napoca, Cluj-Napoca, Romania; 2 Clinica Claros, Barcelona, Spain; 3Hospital San Juan de Deu, Barcelona, Spain Cochlear malformations have been reported to occur in approximately 20% of patients with congenital sensorineural hearing loss. Previously, inner ear malformations were considered contraindications of cochlear implantation. Today they are regarded as indications for cochlear implant and several studies in the literature report very good results, similar to those encountered in normally conformed inner ears. Nevertheless, cochlear implantation in malformations remains a challenge to the implant team. We present the new classification of Sennaroglu for cochleovestibular malformations: 1. Absent or malformed cochlea: Michel deformity, cochlear aplasia, common cavity, coclear hypoplasia, incomplete partition type I, II—Mondini deformity—and III; 2. Normal cochlea: enlarged vestibulary aqueduct and lateral semicircular canal0 s dysplasia. We expose the difficulties encountered in the OR, like: abnormal facial nerve0 s course, the risk of gusher or oozing due to a defect at the lateral end of the internal auditory canal, the challenge to insert the electrode into the cochlea correctly and atraumatically and the risk to insert it into the internal auditory canal. We present the case of a 8 year old girl with bilateral inner ear malformation (incomplete partition type I and dilated lateral semicircular canal on the right side) diagnosed at 2-years old with cophosis on the right side and profound sensorineural hearing loss on the left side, who was unilaterally implanted (right ear) on the 29 May 2008. We describe the preoperative investigations, the surgical technique and the audiological outcome.

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A296 Comparison between ABR and TT-ECochG used intraoperatively for monitoring of hearing during CPAT surgery R. Brzezin˜ski*, K. Morawski, K. Niemczyk Department of Otolaryngology, Medical University of Warsaw, Warsaw, Poland Problem addressed: To investigate and compare two strategies of intraoperative monitoring (IM) of auditory function during cerebellopontine angle tumor (CPAT) surgery: transtympanal electrocochleography (TT-ECochG) and auditory brainstem responses (ABR). Methods: Thirty patients with CPAT were operated using middle fossa approach. Auditory function was monitored intraoperatively using simultaneously TT-ECochG and ABR. Patients were stimulated acoustically by click (75-85 dB nHL). In all TT-ECochG cases the following components of compound action potential (CAP) were analyzed: N1-Amplitude, N1-Latency. In ABR subjects waves III and V were analyzed. Results: Very clear and repeatable CAPs in TT-ECochG strategy were recorded as a result of 64–128 samples averaged. TT-ECochG morphology including N1-Amplitude, N1-Latency were displayed and sufficiently analyzed on-line every 5–7 s. In majority of cases ABR measured simultaneously needed 256 or usually more samples in critical moments of tumor removal showing that it is more effective as a supportive than independent strategy of IM of hearing. Conclusions: TT-ECochG effectively detected even very minimal changes in peripheral part of auditory function in real time domain. A low number of averaged samples of TT-ECochG made possible to update information about hearing status every few seconds. Simultaneously recorded ABR needed usually 3–4 times more samples to recognize any changes in hearing status what consumed more time and delayed final identification of hearing damage. Clinical significance of study: TT-ECochG/ABR strategy may serve as an effective tool for intraoperative monitoring of auditory function during CPAT surgery.

A297 Comparison of auditory steady-state responses and auditory brainstem responses in audiometric assessment of adults with sensorineural hearing loss Y. Chou1*, Y. Lin2, H. Wu2 1 Department of Otolaryngology-Head and Neck Surgery, Buddhist Tzu Chi General Hospital, Taipei Branch, Xindian City, Taipei, Taiwan; 2Department of Otolaryngology, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan Objective: The purpose of this study was to investigate whether Auditory Steady-State Response (ASSR) could be used to predict the hearing level of adults, and whether ASSR could become a

1119 better testing method than Auditory brainstem response (ABR) in audiometric assessment of adults with sensorineural hearing loss. Methods: This was a prospective study, conducted in a tertiary referral hospital. From January to June 2007, 142 subjects (284 ears) with varying degrees of sensori-neural hearing impairment were included. Four frequencies (500, 1,000, 2,000, 4,000 Hz) were evaluated. All subjects received pure-tone audiometry, multi-channel ASSR, and ABR tests for threshold measurement. The correlation of pure tone thresholds with ASSR and ABR thresholds were assessed. Results: Between multi-channel ASSR and pure tone thresholds, a difference of less than 15 dB was found in 71% while a difference of less than 25 dB was found in 89% of patients. The correlation coefficient (r) of multi-channel ASSR and pure tone thresholds were 0.89, 0.95,0.96, and 0.97 at 500, 1,000, 2,000, and 4,000 Hz, respectively. On the other hand, between ABR and pure-tone thresholds, a difference of less than 15 dB was found in 31%; a difference of less than 25 dB was found in 62% of patients. The r correlation value for ABR and pure tone thresholds was 0.83. Conclusion: ASSR is a more reliable test for the accurate prediction of auditory thresholds than ABR. It can be a powerful and convenient electro-physiologic examination tool for clinically assessing of adults with sensorineural hearing loss.

A298 Comparison ossicular chain’s movability before and after reconstruction with the help of LDV method J. Sokolowski*, K. Niemczyk, K. Morawski, R. Bartoszewicz, A. Bruzgielewicz ENT Clinic, Medical University of Warsaw, Warsaw, Poland Aim of study: Evaluation of movability changes in ossicular chain before and after reconstruction and comparison movements of prostheses with different shapes was main aim of the study. Methods and materials: In experiment there were taken 10 temporal bones kept in 5% aqueous formalin’s solution. In first stage were executed: antromastoidectomy with wide tympanotomy. The ossicular chain movability investigation was conducted on: back branch of stapes, front branch of stapes, round window, umbo of eardrum. Laser Doppler Vibrometer was used to measurement ossicular chain’s movability. ER-2 loudspeakers were generated wave: 1,000 Hz, 2,000 Hz, 4,000 Hz. In second stage were executed: Malleus-Stapes Assembly (MSA) ossicular chain’s reconstruction and repeated investigation in measured points. Then we changed shape of prosthesis and estimated its movability. Results: The most convenient points to measurement were respectively: back branch of stapes, front branch of stapes, umbo of eardrum. MSA performance did not influence accessibility of measuring points. Theresholds of measured point’s movability was useful to evaluation of reconstruction. Shape of prosthesis influenced on ossicular chain movements. Conclusions: Back branch of stapes, front branch of stapes and umbo of eardrum are useful to measurements ossicular chain movability. Delimitation thresholds of ossicular chain movability can help

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1120 in reconstruction’s evaluation. After next experiments LDV can be use in practice-intraoperative.

A299 Complication of chronic otitis media D. Djeric* Institute of ENT, Belgrade, Serbia Chronic otitis media with cholesteatoma is a particularly serious otologic disease because of its ability to erode ossicular and labyrinthine bone, leading to complications that include conductive hearing loss, facial paralysis, labyrinthine fistula with sensorineural hearing loss, and intracranial extention with infection. The aim of the study was to investigate the mechanism of development, diagnosis, methods and treatment of complications due to chronic otitis media with and without cholesteatoma.The study included 600 patients who operated due to chronic otitis media. Presenting our results we point out some some diagnostic and therapeutic aspect of the disease. The question is still actual: why an extracranial and intracranial complication is occur, and how can be prevented. We attempt to discuss about occurrence, pathological factors, clinical symptoms, and practical treatment of chronic otitis media and its complications.

A300 Congenital anomaly of ear and its rehabilitations in Uzbekistan M. Jafarov* Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan Purpose: During 1996–2008 we investigated more than 300,000 children in various regions of the Uzbekistan. Depending on region frequency auricular malformation anomalies, such as microtia and anotia, varied from 7 to 16 per 10,000 live births. Per 1 year over Uzbekistan are born more than 500 children with congenital anomaly of ear. The purpose of this research was to find optimum methods for improvement of operative treatment. Material: We were surveyed more than 200 children, which were operated in our clinics. The given operations were made from 1993 till 2008. We have checked up the long-term results for 15 years. The age of children during operation made from 5 till 14 years. Results: If to compare the previous operations which have been carried out till 2003 and operation now it is possible to see on significant improvements of quality of operation. Tactics of operation demanded a basic change all technique of operation. Postoperative care of patients also demanded a basic change. The main thing was absent correct care patients at such operations. Since 2003, in our department’s reconstructive operations on an ear was done under the world standard requirements for ear reconstructions. Conclusion: Observing for development otoplasty for last 15 years, we have seen that developing techniques of operation on reconstruction of an ear, we considerably improved result of operation in Uzbekistan.

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A301 Current trends on ethiology, diagnosis and treatment of tinnitus D. Popova*, S. Varbanova Department of Otorhinolaryngology, Medical University, Sofia, Bulgaria Objective: The main goal of the study is defined tinnitus by an auditory perception in the absence of an external source of sound. Tinnitus is not a disease in itself but rather a reflection of something else that is going on in the hearing system or brain. This condition provides the distinctive possibility of extracting neural coding of perceptual representation, code of phantom perception, in this case auditory. There are many theories as to what causes tinnitus; therefore, there are many treatment options for tinnitus. This study attempts to recognize the etiology and the most appropriate treatment of tinnitus. Materials and methods: In this study, we have tracked patients with subjective ear noise, divided in groups, according to: age; etiology of tinnitus; additional medical states; labor conditions. Clinical diagnosing: In this way, we can determine the kind and degree of hearing loss, the topic of the lesion, and we can exclude retro-cochlear damage, Morbus Meniere, secondary hydrops of the labyrinth, as well as interaction with other diseases. Results: We applied different treatment to the patients in the groups described above, according to the etiology of their conditions, as well as non-medical therapy, with different time spans.

A302 Dizziness, migrainous vertigo and psychiatric disorders R. Teggi1*, D. Caldirola2, G. Perna2, B. Colombo3, G. Comi3, L. Bellodi2, M. Bussi1 1 ENT Department, San Raffaele Hospital, Vita-Salute University, Milan, Italy; 2Anxiety Disorder Clinical and Research Unit, San Raffaele Turro, Istituto Scientifico HS Raffaele, Vita-Salute University, Milan, Italy; 3Department of Neurology, San Raffaele Hospital, Vita e Salute University, Milan, Italy Objectives: Recent works underline the possibility that overlapping neural circuits may produce the co-occurrence of migraine, psychiatric and vestibular disorders. To establish the prevalence of vestibular disorders, migraine and definite migrainous vertigo in subjects referring dizziness and with psychiatric disorders, without lifetime vertigo Methods: 52 subjects with Panic Disorders (PD) and agoraphobia, 20 with PD without agoraphobia and 12 with depressive disorders underwent an otoneurological screening with bithermal caloric stimulation. The prevalence of migraine and migrainous vertigo was assessed. The level of dizziness was evaluated with a Dizziness Handicap Inventory. Results: Patients with PD with and without agoraphobia presented a higher rate of vestibular anomalies (60.3% and 55%) than depressive subjects (25%); agoraphobic subjects had the higher prevalence of peripheral vestibular disorders (32.6%), although no significance was detected between PD subjects with and without agoraphobia (P = 0.13); PD subjects had a higher rate of vestibular anomalies

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 than depressive subjects (P = 0.04). Migraine was equally represented in the 3 groups, but PD subjects had a higher rate of migrainous vertigo. Almost all subjects (18 of 20) with a peripheral vestibular disorder presented definite migrainous vertigo. These subjects had higher DHI scores. DHI total score was higher in subjects with PD and unilateral reduced caloric responses and in patients with definite migrainous vertigo (P \ 0.001). Conclusions: Our data support the hypothesis that dizziness in PD subjects may be linked to malfunction of vestibular system; our data are not inconsistent with the hypothesis that migrainous vertigo is the most common pathophysiological mechanism for vestibular disorders.

A303 Dynamics of pure tone audiometry and DPOAE alteration in Meniere’s disease M. Zatonski*, A. Jablonka-Strom, M. Bochnia Department of Otolaryngology, Faculty of Dentistry, Medical University of Wrocla, Wrocław, Poland Positive glycerol test is recognized as an evidence of the endolymphatic hydrops. However, the course of the glycerol test in consecutive hours after the glycerol intake is hardly described in literature. Purpose: To follow up dynamics of pure tone threshold and DPOAE amplitude alteration in glycerol-positive patients. Material: Selection was made among 45 patients with Meniere’s disease for those having positive glycerol test. Method: Pure-tone audiometry and DP-gram were performed in 4 series: as an initial examination before glycerol intake, 1, 2 and 3 h after. Audiometry glycerol test was regarded as positive when the hearing threshold lowered at least 15 dB at minimum 3 frequencies. DPOAE glycerol test was considered to be positive if DP amplitude increased above 5 dB at minimum 2 DP-gram frequencies. Results: The most significant hearing improvement with relation to initial values was observed after the third hour, especially at the frequencies below 2 kHz. The most dynamic pure tone threshold decrease occurred during the first hour. Between the first and second measurement after glycerol ingestion there was a phase of no significant hearing changes. Further pure tone threshold decrease went on within the third hour. Observing DPOAE changes, the highest DP amplitude growth occurred after the second and third hour at DP-gram frequencies 2, 3 and 4 kHz. The fastest DP-amplitude increase was registered during the first hour after glycerol ingestion. In 11 persons with both audiometry and DPOAE positive glycerol test, parallel dynamics in the course of the glycerol test was observed.

A304 Efficacy of paroxetine HCL in the treatment of tinnitus M. Adnan* ENT Society in Taif, Al-Hada Military Hospital, Taif, Saudi Arabia Objective: To compare the clinical success of seroxite (paroxetine HCL) with conventional treatment in reducing tinnitus. Design: Interventional study, using conventional treatment for one month followed by seroxat for 1 month.

1121 Subjects and methods: Patient with the tinnitus referred from the GP Clinics at Al-Hada Hospital, Taif, KSA. Then were starting of the patient with the examination of the ear, audiogram sometime ABR-MRI examination by the psychiatrist then start with the seroxat. Results: 127 patients with the tinnitus out of the 42 (%) showed clinical improvement from tinnitus with the using of the seroxat for 1 month. Conclusion: There is beneficial effect of the using of the seroxat in the treatment of tinitus properly designed clinical to assertain this effect.

A305 Electrophysiologic evaluation of endolymphatic hydrops D. Masariu1,2*, L. David1,2, A. Tudor2 1 The Ear Clinic, Bucharest, Romania; 2Central Military Hospital, Bucharest, Romania The procedure used to objectify and treat endolymphatic hydrops at the Ear Clinic in Bucharest includes an extended battery of audiologic tests designed to exclude other pathologies and to help locate the lesion topographycally, being followed by the existing treatment methods, including the surgical decompression of the endolymphatic sac. Endolymphatic hydrops is nearly unanimously accepted as the main pathogenic factor in Meniere’s disease. During the period between two crises there are few methods able to highlight the consequences of the hydrops on the inner ear. Electrocochleography (ECoG) is an objective method which evaluates the mechano-electric processes of the cochlea. By using a transtympanic electrode, we can increase the sensitivity and specificity of electrocochleography in detecting the changes in Meniere’s disease. Vestibular Evoked Myogenic Potential (VEMP) measurement gives important information about saccular and inferior vestibular nerve function. Corroborating these two electrophysiologic tests, in addition to the suggestive clinical picture, the Meniere’s disease diagnosis can be sustained in over 90% of the cases. The aim of the present study is to present the variables which are currently regarded as the most important in objectively confirming the clinical suspicion of Meniere’s disease. Keywords: Endolymphatic hydrops, Meniere’s disease, Transtympanic electrocochleography (ECoG), Vestibular evoked myogenic potential (VEMP), Decompression of the endolymphatic sac.

A306 Endaural approach in implantation of the vibrant soundbridge (VSB) long term results W. Hohenhorst*, S. Schro¨der, A. Park Kliniken St. Antonius, Wuppertal, Germany Objectives: The Floating Mass Transducer (FMT) of the VSB system is usually implanted by posterior tympanotomy. In cases with poor pneumatization of the temporal bone and after radical mastoidectomy this retroauricular approach may become problematic. The risk of facial nerve injury, noise or heat trauma, and subluxation of the short process of the incus increases.

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1122 Method: To avoid these potential complications, we perform the FMT implantation endaurally. The procedure starts with an endaural incision according to Heermann. The receiving coil and demodulator are implanted retroauricularly. The conductor link is embedded into a previously created 2–3 mm deep bony sulcus and covered with cartilage strips. Results: Since 2001 we have implanted 12 VSB systems via the endaural approach. Especially in cases with defective ossicular chains (VSB as PORP or TORP with connection to the round window) and after radical mastoidectomy, the endaural approach was very beneficial. A coexisting stenosis of the outer ear canal can be easily widened during this procedure. To date, we have not seen any implant or conductor link extrusion. Conclusion: The endaural approach for implantation of the FMT is relatively easy to perform, safe and stable long term. It is an advantageous alternative to the posterior tympanotomy approach, particularly in revision cases with mixed hearing loss, cases with poor pneumatization of the temporal bone, stenosis of the outer ear canal and after radical mastoidectomy.

A307 Evaluation of apoptosis, proliferation and angiogenesis expression in granulation tissue in chronic otitis media A. Pajor1*, T. Durko1, A. Jankowski1, M. Danilewicz2 1 Department of Otolaryngology, Barlicki University Hospital, Medical University of Lodz, Lodz, Poland; 2 Nefropathology Department, Medical University of Lodz, Lodz, Poland Introduction: There is a growing evidence that molecular and cellular mechanisms may play a role in pathogenesis of the chronic otitis media (COM). The aim of the study was to determine the intensity of apoptosis, proliferation and angiogenesis in granulation tissue in COM of different clinical course. Materials and methods: Fifty-four patients with COM were enrolled into the study. The apoptosis, proliferation and angiogenesis were measured in paraffin-embedded granulation tissue specimens by immunohistochemical methods, by staining with a monoclonal antibodies against apo-1Fas/CD95, P53 protein, Ki67 antigen and CD 34. The study was performed on comparative groups of patients with COM of different clinical course: I group—25 patients NR (no recurrence); II group—29 patients R (recurrence). Results: There were statistically significant differences between NR and R groups of patients with COM in mean values of APO1/Fas positive cells (1.52 vs. 3.34 respectively, P \ 0.001), Ki67 antigen positive cells (9.06 vs. 11.08 respectively, P \ 0.001) and intensity of CD34 antigen (694.9 vs. 468.7 respectively, P \ 0.002). The significant correlations were found between expression of apo-1/Fas antigen and P53 protein (r = -0.64, P \ 0.001), apo-1/Fas antigen and CD34 (r = -0.35, P \ 0.05), apo-1/Fas antigen and Ki67 (r = 0.46, P \ 0.001) and Ki67 and P53 protein (r = -0.42, P \ 0.002). Conclusions: Different expression of apoptotic, proliferative and angiogenetic markers in relationship to clinical course of disease may suggest that these molecular mechanisms may contribute to pathogenesis of chronic otitis media. Granted by Medical University of Lodz, grant no 502-11-454.

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A308 Evaluation of auditory function in beta-thalassemia patients treated with deferasirox E. Gerostergiou1, I. Tsitiridis1, V. Lachanas2*, G. Karatzias1, E. Gletsou2, M. Chorti3, E. Exarchou4, Z. Bessas3, P. Karagounis1, T. Kaffes3 1 Audiology Department, General Hospital of Larisa, Larissa, Greece; 2Otorhinolaryngology, Head and Neck Surgery Department University of Thessaly, School of Medicine, Larissa, Greece; 3ENT Department, General Hospital of Karditsa, Karditsa, Greece; 4Internal Medicine Department, General Hospital of Karditsa, Karditsa, Greece Introduction: With the improved life expectancy of thalassemic patients, new clinical problems, such as hearing loss, must be evaluated. Objective: To evaluate the auditory functionality in beta-thalassemic patients and its relationship to deferasirox in which patients are treated with 20–30 mg/kg per os through out life. Materials and methods: We examined the auditory function in 55 patients in ages between 15 and 45 years old affected by beta-thalassemia and regularly treated with 20–30 mg/kg/day of deferasirox. Otological examinations and pure tone audiometry were performed on the patients to find evidence of drug-induced auditory abnormalities. Results: From all of the patients 25 were male and 30 female. According to audiological examination 61.8% (34 patients) of the patients had a normal auditory functionality. 16.3% (9 patients) of the cases had a sensorineural hearing loss with a slope in high frequencies and 16.3% (9 patients) a slope in low frequencies and 7.27% (4 patients) tinnitus. Conclusions: According to this study beta-thalassemic patients must be under periodical audiologic checkups in order to prevent and prompt diagnosis of audiological complications.

A309 Facial paralysis in mastoiditis S. Blazic*, D. Djeric Institute of ENT, Belgrade, Serbia Although the frequency of otogenic facial paralysis has decreased since the Introduction of antibiotics, it still occurs in an estimated 1% of patients with chronic middle ear infection. An acute exacerbation of infection in cholestematous chronic suppurative otitis media is a major factor in the aetiology of facial paralysis. Both acute and chronic mastoiditis it is are potentially serious disease because of the complications caused by progressive osteitis and bone erosion. The purpose of the present study is to report our experience in diagnosis and treatment of mastoiditis with associated facial paralysis. Ten patients with an active chronic otitis media and mastoiditis were included. Most of them had a history of chronic middle ear infection for long period of time, but have been diagnosed and treated

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 sufficientlly. The most common symptoms of the disease were otalgia, otorrhea and hearing loss, but the signs of mastoiditis were also presented. Facial paralysis was found in four patients. CT scan as used for determination of the pathological process in the middle ear spaces. The patients were treated surgically and with antibiotics. In cases with facial paralysis a facial therapy has been applied postoperatively. Mastoiditis with post-auricular abscess or/ facial paralysis is still an otological emergency problem in our Institute. Early diagnosis and adequate treatment is most important to prevent a serious complications of mastoiditis.

A310 Genetic testing for paraganglioma H. Neumann1*, D. Zabolotny2, Z. Erlik2, S. Yaremchuk1 1 Preventive Care Unit, University Medical Center, University of Freiburg, Freiburg, Germany; 2Institute of Otolaringology AMN of Ukraine, Kiev, Ukraine The paraganglioma syndrome is the heading for 4 subtypes. In 3 of them the susceptibility genes have been identified: Succinyldehydrogenase subunit B (SDHB), subunit C (SDHC), or subunit D (SDHD). Most patients have mutations in the SDHD gene or SDHB gene. We examined 34 Ukrainian patients suffering from paraganglioma situated in the head and neck area. The blood sample collected from patients who have been operated previously. We used 10 ml EDTA blood for genetic investigation which was performed in Freiburg, Germany. We revealed mutation in 10 patients. Investigation of catecholamine level and MRI investigation abdomen and thorax region was performed in all cases of mutation. Family anamnesis was positive in one case. Genetic testing of additional members of the families showed the mutation in 3 families and disclosed the mutation in 5 cases. In conclusion we suggest to test HNP patients for SDHx mutations.

1123 occurred and adjuvant radiotherapy was carried out. Careful clinical evaluation and imaging studies (CT, MRI) of the temporal bone and the scull base are very important for the diagnosis of glomus tympanicum. Surgical removal is the treatment of choice, while in patients where surgery is not possible radiotherapy is indicated.

A312 Head and neck paragangliomas: our experience S. Stoyanov1*, K. Assenova2, H. Zlatanov2 1 Ministry of Interior, Medical Institute; 2Military Medical Academy, Sofia, Bulgaria Introduction: Paragangliomas are benign, slow growing tumours that arise from neuroectodermal tissues. They can occur anywhere along the sympathetic paraganglial chains. In the head and neck, two anatomic groups of paragangliomas can be differentiated: cervical paragangliomas and temporal bone (jugulotympanic) paragangliomas. The cervical group includes carotid body tumours and glomus vagale tumours, while the jugulotympanic comprises glomus jugulare and glomus tympanicum tumours. Glomus tympanicum tumours are more common than glomus tumours around the jugular vein, and are the most common primary neoplasm of the middle ear and the second most common tumor of the temporal bone. Aim: To share our experience with HN paragangliomas and discuss diagnostic and treatment options. Material: We present two clinical cases. A 50 years old lady with right sided glomus tympanicum tumor and a very rare case of a 47 years old man with bilateral multiple glomus caroticum tumors. Conclusion: Paraganglioma need careful consideration and early surgical removal. Residual tumors may require postoperative radiotherapy or observation with MRIs with long term follow up with ENT examinations. The well-planned and prepared gentle surgery and the collaboration with angiographists and vascular surgeons are crucial for the successful treatment.

A311 Glomus tympanicum: the experience of our department

A313 Hearing loss in children with enlarged vestibular aqueduct in 23 cases

C. Evaggelopoulos, E. Gletsou, C. Gantas, P. Pavlidis, C. Makrypidis, E. Theos, V. Lachanas*, T. Apostolidis Otorhinolaryngology, Head and Neck Surgery Department, School of Medicine, University of Thessaly, Larissa, Greece

S. Santos1*, L. Sgambatti2*, M. Dominguez1*, E. de la O3*, A. Suarez1, A. Bueno1 1 Hospital Nino Jesus, Madrid, Spain; 2Hospital Clinico Universitario de Salamanca, Salamanca, Spain 3Complejo Hospitalario de Cacares, Ca´ceres, Spain

Glomus tumors, also called paragangliomas originate from non-chromafin cells. The tumor is vascular and slowly grows from capillary and pre-capillary vessels in between epithelial cells. The most common symptoms are tinnitus and hearing loss. We present 3 patients with glomus tympanicum treated in our department between 2001 and 2007. All three patients were women, 65, 68 and 73 years old. Patients’ symptoms were unilateral tinnitus and hearing loss. Furthermore in the third case facial nerve palsy, hoarseness and dysphagia was noticed. Audiologic evaluation, CT and MRI scans of the brain and temporal bone were obtained. All three patients were treated with surgical removal of the tumor through tympanic mastoidectomy. In all cases the follow up period was approximately 4 years. In this time period two of three patients remained free of symptoms. In one case recurrence

Objective/hypothesis: To explore the clinical characteristics and audiologic outcomes in children with enlarged vestibular aqueduct (EVA). Study design: Descriptive and retrospective study in a pediatric tertiary care facility. Methods: A total of 23 cases (8 females, 15 males) of children with EVA were identified with complete records, including otologic evaluation, imaging studies, and audiologic assessments. The diagnosis of EVA was confirmed by computerized tomography scan/magnetic resonance imaging of the temporal bone. Hearing status was assessed using behavioral testing or auditory brainstem response (ABR). Results: Of 23 cases 87% of our EVA cases showed bilateral involvement, 13% show unilateral involvement, Sensorineural HL

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1124 was diagnosed in 43 ears, 19 patients (36 ears) has profound sensorineural HL and 4 patients (7 ears) has severe sensorineural HL, 2 patients (9%) has a Down syndrome. 12% of all ears with EVA also had cochlear malformations, such as Mondini dysplasia. Conclusions: Our data show the frequent role of the large vestibular aqueduct syndrome in the pathogenesis of sensorineural hearing loss and the overall wide variability in its audiological features. It is also highlighted that EVA is often part of some syndromal diseases.

A314 Hearing preservation in patients with labyrinthine fistula A. Gocea1*, B. Martinez-Vidal1, C. Panuschka1, P. Epprecht2, M. Bernal-Sprekelsen1 1 Servicio de ORL, Hospital Clinic, Barcelona, Spain; 2 Servicio de ORL, Hospital Son Dureta, Palma de Mallorca, Spain Background: Management of labyrinthine fistula has been controversely debated in literature for years. In these cases hearing preservation represents a challenge for otologic surgeons. Methods: We conducted a retrospective study on 28 patients with labyrinthine fistula, confirmed during cholesteatoma surgery. In all cases total matrix removal was performed, the fistula covered with bone dust, periosteum and/or cartilage. Twenty-three patients received a high dosage (500 mg) i.v. steroids, 15 min before handling the fistula. Outcome measurements included the comparison of the preoperative and postoperative bone conduction to assess the inner ear function. Results: 22 fistulas (78.57%) were located on the lateral semicircular canal (LSC), 5 on the oval window (OW) and 1 involved both the superior and lateral semicircular canals. There were 5 type I fistulas (17.85%), 8 type IIa (28.5%), 4 type IIB(14.4%) and 6 type III (21.40%) according to Dornhoffer and Milewski0 s classification. Preoperatively, the bone conduction displayed an average threshold of 34 dB. Patients treated with steroids showed a preserved or improved bone conduction in 70%. Patients with OW and type IIa LSC fistulae treated by cortisone experienced a good sensorineural hearing outcome whilst auditory results for groups IIb and III are rather unconclusive. 3 of 5 patients not receiving cortisone developed a partial sensorineural hearing loss and one got deaf. Conclusions: Complete cholesteatoma matrix removal over the fistula after high dosages of i.v. metilprednisolone, followed by its repair, seems to be helpful in preventing permanent inner ear damage and even to improve bone conduction in patients with oval window or type IIa fistulae of the LSC.

A315 Hearing recovery using the torp after radical trepanation of temporal bone D. Rancic* ENT Clinic, Clinical Center Nis, Nis, Serbia Aim was to use prosthesis for hearing recovery in patients with hearing imairment after radical trepanaton of temporal bone. This

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 operation means mastoidectomy, antrotomy, cleansing all ossicles and closure the tube (Eustachian). It was performed by patients with large cholesteatomas. In six patients the same operative procedure was performed in two stages. In two those procedures hearing geting much better for air-conduction and for bone-conduction too. Audimetric and AEP (auditive evoked potentials) are followed-up preoperatively, after stage one and 1 month postoperatively. Results for all patients shows better hearing, and shorter time of conducting trought the nerve. This work represent an original operative method in case hearing impairment after radical trepanation of temporal bone.

A316 Hearing restoration in conductive and mixed hearing losses using the Vibrant SoundbridgeÒ R. Hagen1*, R. Mlynski, J. Mu¨ller 1 Universita¨tsklinikum, Wu¨rzburg, Germany In many cases of conductive and mixed hearing losses attempts to get a satisfactory hearing using classical middle ear approaches are not successful. This is mainly due to the basic pathology, f.e. a missing tubal function, adhesive processes, malformations or inner ear involvement in otosclerosis. In these patients fitting of a conventional hearing aid also fails to provide a sufficient speech intelligibility. The Vibrant Soundbridge proved to be a very reliable active middle ear implant in cases of high frequency hearing loss in patients with difficulties using a conventional hearing aid. Coupling the floating mass transducer (FMT) of this device to a middle ear prosthesis (PORP, TORP) or the direct attachment of the FMT to the footplate, the round window membrane or a promontory window facilitates a hearing restoration in these difficult cases with very convincing results in speech intelligibility. The different possibilities of this new application of the Vibrant Soundbridge were used in about 30 cases with difficult middle ear conditions. The audiological outcome so far was much better than with all other measures tested before. The mean hearing gain was between 20 and 50 dB, depending on the individual pathology and the used technique of FMTcoupling. In spite of difficult middle ear conditions in many of these cases, we had so far no severe complications following the implantation, in particular we found no significant postoperative reduction of bone conduction thresholds.

A317 Hearing screening of NICU population in Cyprus: a comparison study A. Asrpis, M. Ioannou, M. Kallimahou, G. Komodikis*, K. Argiris, I. Kyamides Nicosia General Hospital, Nicosia, Cyprus The objective of this retrospective study was to investigate the incidence of hearing impairment in the Neonatal Intensive Care Unit (NICU) in Cyprus during 2006, to report the diagnostic referral rates, and to characterize the prevalence of risk factors of the neonates with hearing impairment. Comparing the results of this study with published data from other countries will provide information regarding the success of the hearing screening program. All the infants in the NICU were screened using a Transient Evoked Otoacoustic Emission

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(TEOAE) screening test before their discharge from the hospital. The TEOAE test was then repeated a month later. An Auditory Brainstem Response (ABR) test was performed on the babies that twice failed the TEOAEs. A detailed history of risk factors was collected for each neonate. A total of five hundred seventy-five (575) infants were screened in 2006. Seventeen (3.0%) infants were referred for an ABR following the two TEOAE screenings. Four (0.7% of the total) of the referred infants had normal hearing, 5 (0.87%) had conductive hearing loss, and 6 (1%) had bilateral sensorineural hearing loss of various degrees. 2 infants had unilateral atresia with normal hearing in the contralateral ear. The risk factors of the infants diagnosed with bilateral sensorineural hearing loss will be discussed. Hearing screening in our NICU population revealed hearing loss in 1% of the population, within the range of published data. The results of the study were used to further improve the NICU hearing screening program.

Results: The analyzed population of patients was divided with regard to the preoperative values of bone conduction (as the average for 500 Hz, 1,000 Hz and 2,000 Hz) into three groups. A considerable improvement in hearing quality as early as 6 months after the surgery was observed in the group with correct bone conduction. An improvement was also observed at bone conduction values oscillating between 21 and 40 dB, though during longer periods of observation for 12 months. Increased perceptive hearing loss ([40 dB) was coexistent with the absence of considerable hearing improvement after otosurgery. Conclusion: Severe perceptive hearing loss is an unfavourable condition for hearing improvement in the patients with chronic otitis media.

A318 Indications, surgical techniques and results of implantation of the FMT of the Vibrant Soundbridge hearing system directly onto the round window

T. Gierek, W. Smolka*, L. Klimczak Gołab, J. Paluch ENT Clinic Katowice, Katowice, Poland

E. Savvas*, J. Maurer Katholisches Klinikum Marienhof, Koblenz, Germany Introduction: The reconstruction of middle ear ossicles using passive implants does not always result in a sufficient functional outcome. Conventional hearing systems are usually not adequate in helping patients with severe combined hearing losses, or cannot be used by patients with discharging radical ear cavities. Patients: Due to these limitations of passive implants, we implanted 10 patients in the past 2 years with the semi-implantable hearing system Vibrant Soundbridge (MedEl) with direct insertion of the floating mass transducer onto the round window. Results: All patients showed an extraordinary postoperative hearing gain, even in comparison to the best fit hearing aid preoperatively. Conclusion: The semi-implantable hearing system Vibrant Soundbridge (MedEl) is well suited for the hearing amplification and rehabilitation of patients in which other conventional methods are not appropriate. The indications, surgical techniques and results will be discussed here in detail.

A319 Influence of bone conduction threshold on hearing results after middle ear surgery M. Wiatr*, J. Skladzien, J. Tomik, K. Oles Department of Otolaryngology, Jagiellonian University, Krakow, Poland Introduction: The only successive and permanent method to treat chronic otitis media is otosurgery. Aim: The authors searched for the link between an increase in perceptive hearing loss and the effectiveness of tympanoplastic operations. Materials and methods: Prospective analysis of the patients operated on for the first time due to chronic otitis media was performed. 147 patients operated on in the years 2004–2007 met the criteria to qualify for the analysis.

A320 Long term hearing results after stapedotomy

In this study we investigated the long term hearing results of 90 stapedotomies performed between 1995 and 1997. The aim of this study is to analyze and compare long term hearing results in 3 groups of patients undergoing stapedotomy. The patients were divided into 3 groups A, B and C according to Shambough (depending on preoperative bone conduction level), each consisting of 30 patients. The study population consisted of 71 women (78.9%) and 19 men (21.1%). The average age of the patients in group A was 35.6 years (SD = 9.2), in group B 41.7 years (SD = 8.1) and in group C 44.8 years (SD = 7.0) and 40.7 years overall in the three groups. The youngest patient was 21 years old, the eldest 58. All the patients enrolled in the study underwent audiometric assessments preoperatively and 1 month, 1 year and 10 years postoperatively. The followup period was 10 years. The results presented allow to reach the following conclusions: 1. The cochlear reserve values were constant over the 10-year observation period. 2. The best bone and air conduction values over the 10-year observation period were observed in patients classified to group A according to Shambough. 3. Patients in group A obtained the best average speech audiometry results in the 10-year postoperative follow-up examination. 4. Primary assessment of AC and BC thresholds should be done 12 months postoperatively.

A321 Management and results of the Vibrant Soundbridge implantation in patients with auricular atresia S. Arndt*, W. Maier, R. Beck, C. Schild, T. Wesarg, R. Laszig, A. Aschendorff Department of Oto-Rhino-Laryngology, Head and Neck Surgery, University Medical Center Freiburg, Freiburg, Germany Congenital auricular atresias are often combined with malformations of the ossicles. The patients suffer from conductive hearing loss with an airbone gap of 50 to 60 dB. Conventional bone-conducting or bone-anchored hearing aids are treatment options with several disadvantages like skin inflammation. Additionally, some

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1126 patients refuse implantation of a screw. Implantable hearing aids have been developed for patients with perceptional hearing loss and normal middle ear function, but not for patients with middle ear disease or malformation. We present five cases of auricular atresia to illustrate the management of hearing rehabilitation using the active middle ear implant Vibrant Soundbridge (VSB). The preoperative diagnostic investigations and surgical planning are discussed. In selected cases, it was useful to plan the surgery with a simulator for temporal bone surgery. It is possible to load the computed tomography records of the patient into the system and to create three-dimensional simulation of the surgery. Using this simulation of the preoperative surgical access in these patients, and additionally by using navigation during surgery, the risk of surgery can be significantly reduced. The VSB was attached to the incus in three cases and directly to the membrane of the round window in two cases. The results of hearing rehabilitation, especially directional hearing and hearing in noise, are discussed.

A322 Mastoidectomy with obliteration as a treatment for middle ear atelectasis L. Hoep*, P. Merkus, E. Hensen, F. Smit VU Medical Center, Amsterdam, The Netherlands Middle ear atelectasis is a slowly progressive disease that can cause pressure feeling, hearing loss and sometimes cholesteatoma. Aetiology of middle ear atelectasis is unknown. We hypothesize that it is a disease of mucosal gas exchange. Objective: Pilot study to evaluate (long term) effectiveness of obliteration mastoidectomy and tympanic restoration for grade III to IV middle ear atelectasis. Subjects and patients: with grade III to IV atelectasis with at least 25 dB hearing loss. Intervention Mastoidectomy with removal of all mucosa, closure of antrum followed by mastoid obliteration with bone dust and fibrin glue, reconstruction of tympanic membrane and incus interposition was performed. Results: In all 8 patients, severe and progressive complaints of their atelectasis disappeared. Tone audiometry, ear pain, pressure feeling and infection all improved in the obliterated ear. The grade of atelectasis changed in 6 of 8 patients to a normal ear drum and in the other two patients improved to grade I and III. The follow up period was at least 18 months (18–29 months). In the contralateral ear all patients had an unchanged or worsened grade of atelectasis. Conclusion: Obliteration of the mastoid with bone dust seems a solution for middle ear atelectasis and prevents recurrence of atelectasis in the majority of patients. The results of this pilot study support the hypothesis that atelectasis (and cholesteatoma) is a disease caused by negative middle ear pressure due to altered gas exchange of diseased middle ear mucosa. Further research to this concept is being performed.

A323 Meatoconchoplasty in mastoid surgery for chronic suppurations: our 15 years experience E. Anghel, J. Becherescu* Institute of Phonoaudiology and ENT Surgery ‘‘Prof. Dr. Hociota’’, Bucharest, Romania

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Meatoplasty is an essential stage of the canal wall-down mastoidectomy. It consists in posterior wall resection of external acoustic meatus, providing a common tympanic-mastoid open cavity. We consider the term meatoconchoplasty (MCP) to be more adequate than meatoplasty because conchal incision needs to be made as part of the technique. We present in a retrospective study our 15 years experience in mastoid surgery, analyzing almost 1,200 patients who underwent canal wall-down mastoidectomy. We correlate patients anatomical, pathological and surgical particularities with procedures we chose. Our study highlights main causes of meatal stenosis and subsequent persistence of otic suppuration: inadequate conchal cartilage resection, anterior shift of ear pavilion, accidental intraoperative skin disruption and its subsequent infection. We establish the risk factors involved in postoperative failure: age under 16, hypertrophic scarring, presence of Pseudomonas aeruginosa in ear secretion and its association with Staph. aureus or Proteus spp., presence of proliferative polypoid otomastoid lesions. Of grate importance for successful MCP is an appropriate conchal cartilage resection. Although the surgical technique needs to be strictly and meticulously followed, it should be adapted on patients local and general particularities. Surgeons experience and accurate performance of the procedure are essential for managing intraoperative incidents (dura mater, lateral sinus or facial nerve lesions) and avoiding late meatal stenosis. Keywords: Mastoid surgery, Open cavity, Meatoconchoplasty

A324 Mechanisms and arguments for assessing bone conduction hearing thresholds in otology R. Dauman* University of Bordeaux, CHU of Bordeaux, Bordeaux, France Purpose: (a) To actualize the mechanisms of bone conduction; (b) to demonstrate that measurement of bone conduction hearing thresholds is crucial in middle and inner ear surgery, both in adult and pediatric populations. Methods: (a) Review literature published since 2000; (b) analyze air condution and bone conduction hearing thresholds in middle ear surgeries performed in our ENT department over year 2006. Results: Discussion will be focused on outcomes of stapes surgery.

A325 Mild form of Treacher–Collins syndrome: a case report K. Zelenik*, P. Kominek, T. Pniak Otorhinolaryngology Department, University Hospital Ostrava, Ostrava, Czech Republic Introduction: The incidence of minor congenital anomalies of the middle ear is very small. They are often associated with syndromes (most often Treacher–Collins syndrome). The dominant symptom is conductive hearing loss from childhood. Diagnosis in a child is usually made by medical history, audiometry and tympanometry. CT scan might by useful. Sometimes, it is not possible to distinguish between the congenital and otoclerotic stapes fixation, particularly in young patients with uncertain history about hearing loss onset. Case report: A 15-year-old girl was presented with right side hearing loss without dizziness or tinnitus. She asserted that problems had begun 3 years ago. She had no abnormality of the auricle, ear

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 canal, as well as tympanic membrane. However, we noticed very mild retrognathia. Audiometry showed moderate conductive hearing loss and tympanogram. A curve without stapedial reflexes. Explorative tympnotomy was performed for suspected otosclerosis and stapes ankylosis, monopodial stapes with a small footplate and facial canal anteposition were revealed. Stapes was carefully removed. Because of anteposition of the facial canal bone, there was no possible to use piston prothesis, so that TORP was used. Postoperative audiogram is normal. The final diagnosis was mild form of Treacher–Collins syndrome. Conclusions: Patient information about onset of the hearing loss might be confusing. Even minor facial variabilities in patients with conductive hearing loss should lead us to consider middle ear innate anomaly. TORP can be used for reconstruction in cases with facial canal bone anteposition.

A326 Moderate hearing loss [40 dB can be found with single-question method in elderly population in Finland M. Jaakkola1*, J. Salonen1, R. Johansson1, S. Karjalainen1, T. Vahlberg2, R. Isoaho3,4 1 Department of Otorhinolaryngology Head and Neck Surgery,Turku University Hospital, Turku, Finland; 2 Department of Biostatistics, Turku University, Turku, Finland; 3Institute of Clinical Medicine, General Practice, University of Turku, Turku, Finland; 4Pori Health Center, Pori, Finland Moderate hearing loss [40 dB can be found with single-question method in elderly population in Finland. The Finnish version of the Hearing Handicap Inventory for Elderly Screening (HHIE-S) questionnaire was tested in an elderly population in Finland. The usefulness of the HHIE-S and its comparability with simple single-question method was evaluated in 164 elderly people (70–85 years of age). The results of the two questionnaires were compared to the audiometric measurements. Pure tone averages at 0.5–4 kHz were used to define the mild and moderate hearing loss ([25 dB and [40 dB, respectively). The results at hearing level [35 dB were also analysed. The singlequestion used was ‘‘Do you feel you have a hearing loss?’’. For the detection of moderate or worse hearing loss, the HHIE-S cut-off score of [8 had a sensitivity of 100% and specificity of 59.7%, while the single-question had a sensitivity of 100% and specificity of 70.7%. The single-question test correlated to the hearing level [35 dB with sensitivity of 91.7% and specificity of 75.2%. Significant correlation between HHIE-S and single-question test was found at hearing levels of [35 dB and [40 dB. The elderly people with considerable hearing loss with difficulties in everyday life can be found with this simple single-question test and it can be used to evaluate the need for audiological rehabilitation in an elderly population.

1127 Introduction: Cochlear implants still have numerous limitations in their use. The chance for successful implantation is questionable in patients with middle or internal ear malformations, in cases after radical mastoidectomy or chronic otitis media. The aim of the study was to assess the anatomical predispositions for successful accomplishment of modiolar implantation of human temporal bone. Methods: 10 dissections of human temporal bones were carried out. An experimental electrode was introduced into the modiolus to asses the appropriate length of the ‘‘modiolar electrode’’. Results: It was found that the appropriate surgical approach to the modiolus is through middle cranial fossa. Electrode with length of about 8–10 mm can be implanted without fatal damage the nerve trunk. Our histological studies showed details of modiolar anatomic structures. Conclusion: Based on the experiment’s results, we can consider that implantation in the modiolus could be possible. Modiolar implantation could be an alternative to standard CI initially in cases with severe cochlear ossification and some form of cochlear malformations.

A328 Music induced hearing loss S. Abdi* 1 Tums, Tehran, Iran Background: With massive growth of enviromental noises, many people putting themselves at risk for hearing loss. Our research is relatively cross sectional study and purpose was to find association between listening to loud music and hearing loss.We have done pure tone audiometry for all patients. Evaluated 250, 500, 1,000, 2,000, 4,000, 8,000 kH and the mean of hearing thresholds was normal (12 dB) for all frequencies. Tympanometry was normal, AR was present. Methods: All the patients were asked about their habits during listening to music or using headphones, divided them into two groups based upon loud music listeners (group 1) include 60 patients, aged (15–30) years old and headphone users (group 2) include 60 patients,aged (15–30) years old. Hearing evaluation were done at first visit and after 6 months. Patients in group 1 were listening to music with average of 2–4 h per day at 90–120 db. Group 2 were using headphones and frequency usage for this group was three or more times in a week, with an average of 30–150 min in each use at 104 db. Results: We repeated after 6 months. Frequencies at 2,000, 4,000 and 8,000 showed a tendency of being higher than their past for both groups. The mean of hearing thresholds was increased to 20 db for group 1and 25 for group 2. Conclusion: As hearing impairment rise among people specially teenagers we approach to a deeper research to find relation between listening to loud music and hearing loss.The results have shown loud music can cause damage to hearing and headphone users are suffered more.

A327 Modiolar anatomy and chances for modiolar implantation

A329 Myringoplasty by under-lay aproach

T. Karchev1*, S. Stoyanov2*, K. Asenova3* 1 ENT Chair, Medical University Sofia, Sofia, Bulgaria; 2 ENT Clinic, Medical Institute, Ministry of Interior; 3 ENT Clinic, Military Medical Academy, Sofia, Bulgaria

A. Andrei*, S. Vetricean, I. Antohi, E. Cernolev, A. Bajureanu, C. Eremia Department of Otolaryngology, University of Medicine and Pharmacy ‘‘NicolaeTestemiþanu’’, 2025, Testemitanu str., Chisinau, Republic of Moldova

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1128 Objectives: The studies were done on analyzing of anatomical and functional outcomes about myringoplasty by ‘‘under lay’’ technic— the placement of autofascial graft under meato-tympanal flap. Methods: The study was done on 137 patients with age between 7 and 60 years old. The operations were performed at Central Hospital and Central Hospital for children of Republic of Moldova. Results: The closure of tympanal perforations was obtained in 76.92% of cases. In 13.85% of cases were observed a small perforation of ear drum. Necrosis of fascial graft was in 9.23%. In the patients with age between 7 and 15 years old the closure of tympanal perforations was in 89.6% of cases. Air-bone gap was reduced in 90.8% of cases. Conclusions: The performing of myringoplasty by a ‘‘under-lay’’ method assures better placement of fascial graft in a reception zone of ear drum, increases the contact surface of graft with tympanic membrane, in most of cases avoids phenomenon of lateralization. Anatomical and functional results were better in children that in adults.

A330 New bone anchored hearing aids: evaluation of mechanical and audiological solutions for a new direct bone conduction system P. Westerkull1*, T. Rosenbom2 1 Otorix, 2Oticon, Askim, Sweden Bone anchored hearing aids—evaluation of mechanical and audiological solutions for a new direct bone conduction system. Objectives: The objective was to investigate design aspects and performance of a new coupling arrangement for an improved Direct Bone Conductor/Bone anchored hearing aid. The coupling arrangement for a Direct Bone Conductor is of decisive importance from clinical, biomechanical, acoustic and durability aspects. Furthermore, the latest hearing aid technology with advanced microphone technology, signal processing and individual fitting was implemented into a Bone anchored hearing aid system. The outcome results were used for the development of a new Oticon based bone anchored hearing aid. Method: A coupling design with separated and optimised spring/ contact material was investigated using mechanical wear test rig and force-displacement measuring instruments. Long term coupling performance and audiological transmission was measured. Signal processing features was investigated and viewed from audiological and user related aspects. Results: The results showed significant improvements of long term performance of the coupling arrangement, and indicate that modern hearing aid technology will offer benefits for direct bone conduction devices. Conclusions: The conclusion is that a separated spring/contact material design of a direct bone conduction coupling can offer significant biomechanical and durability improvements. Furthermore the introduction of high end hearing aid technology offers several possible user related benefits in terms of improved individual frequency shaping, sound processing as well as the individual setup of the practical function of the device for the user.

A331 Occupational hypoacusis at workers of oil industry of Azerbaijan S. I. Goyushova*, F. G. Djavadov The Central Hospital of Oil Explorers, Baku, Azerbaijan

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Workers of oil industry are classified as ones who belong to traditionally harmful professions. Occupational neurosensory hypoacusis developing from influence of intensive industrial noise is an actual problem for workers of oil industry. The sources of intensive industrial noise at the oil refining enterprises are technological furnaces, pumps, compressors. It is necessary to specify, that on modern manufactures in connection with the increased capacity of centrifugal pumps and application of condensers of air cooling there is observed increase in intensity of noise from the fire heaters working on gas fuel, intensity of noise is lower, than from the fire heaters working on liquid fuel, by spraying of water steams. According to the technical indications 520 gauging of noise on various sites of oil refining factory have been made. At extremely admitted standards noise of 85 db power of noise at fuel injector of a furnace reaches 104–115 dB. On a site between furnaces power of noise was also above extremely admitted standards and made 88–92 dB. In pump premises the level of noise was a little above, than at fuel injector of a furnace and also makes 86–97 dB, and one of compressors 93–96 dB. Noise in the middle of operational premises is low-frequency and is in limit of sanitary standards 70–77 dB.

A332 Ossicular reconstruction with auto-homologous materials (cartilage, bone) M. Cosgarea*, A. Maniu, V. Necula, M. Chirila, S. Pop Univerita¨ts HNO klinik, UMF’ Iuliu Hatieganu’, ClujNapoca, Romania The reconstruction of middle ear and its function after distructive pathology of the eardrum with or without affectation of the ossicular chain, assuring in the same time the sterility of the new created tympanic cavity, is a big concern of the ENT Clinic ClujNapoca. Relying on the literature data the authors have performed the middle ear reconstructions after chronical inflammatory diseases of the tympanic cavity and also after cholesteatoma removal surgery. To reconstruct the anatomy and function of the affected ear we used materials like: tragal or conchal cartilage, perichondrium (alone or alltogether), temporal muscle fascia, ossicles unaffected by the infectious process, fragments of mastoidian corticale and prosthesis (PORP or TORP). The study was carried on a period of 7 years (2000–2007) 709 cases; the results and discussions establish the importance of reconstructing the ear at all cases that fulfill the anatomic and sterility conditions required by the surgical techniques.

A333 Ossiculoplasty: results and prognosis H. Kazmierczak*, K. Pawlak-Osinska, W. Kazmierczak ORL Department, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland The purpose: The aim of the study was to evaluate the eradication and tympanomplasty techniques in chronic otitis media. Materials and methods: The analysis was carried out in 120 patients, 65 male and 55 female, aged 17–62. In all cases computed tomography of temporal bones was done. The combined approach tympanoplasty was performed in 92 patients; the canal wall-down procedure in 28 cases. In interposition technique autografts were used. Myringostapediopexy or myringoplasty alone were made in some patients.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Results: The audiological examination checked 6–12 months after operation showed 15–25 dB improvement of the hearing in 85% of cases. The authors discussed the possible causes of the unsuccessful operations in the rest of patients. The main reason of the worse score in the eradication of the ear and the tympanoplasty were: repeated operation, antral mucosa pathology, bilateral ear disease, diabetes mellitus or rheumatoid disease.

A334 Otologics fully implantable hearing device pivotal trial results H. Jenkins1, V. Lupo1, S. Claycomb1, J. Atkins2, M. Nichols3 Withdrawn

A335 Otoxicity caused by once- and twice-daily administration of amikacin in rabbits P. Pavlidis1,2,4*, V. Nikolaidis1, H. Gouveris2, E. Papadopoulos3, G. Kekes1, D. Kouvelas4 1 2nd Department of Otolaryngology, School of Medicine, Aristotle University, Papa, Thessaloniki, Greece; 2 Department of Otolaryngology, School of Medicine, University of Thessaly, Larissa, Greece; 3Veterinary School, Aristotle University of Thessaloniki, Thessaloniki, Greece; 4Laboratory of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece The cochleotoxic effects of aminoglycosides, such as amikacin, are wellestablished. The aim of the present study was to investigate possible differences in cochleotoxic effects between once (ODA) and twice-daily administration (TDA) of amikacin simulating pediatric dosing. Twentyone rabbits were used. Seven animals received intramuscularly amikacin once-daily (ODA-group) and seven received the drug twice-daily (TDAgroup), for a total time period of 2 weeks. All the animals were subjected to Distortion Products Otoacoustic Emissions (DPOAEs) every three days since beginning of the experiment. The rest 7 animals remained intact and served as controls (Control group). Two measurements (7 and 14 days) were obtained following the cease of drug administration. Reduced cochlear activity (as depicted in the respective reduced DPOAEamplitudes) compared to the pre-treatment state was found in both ODAand TDA-groups. Cochlear activity was reduced at a wider range of frequencies (from 593 to 4,031 Hz in TDA-group and from 593 to 1,093 Hz in ODA-group) and to a higher degree in group B than in group A. Cochlear activity was reduced earlier in ODA-group than in TDAgroup. No differences to the pre-treatment state were observed in the control group. The above findings suggest that less frequent administration is associated with minimal cochleotoxicity.

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A336 Our experience in the selection and evaluation of cochlear implant candidates K. Assenova1, S. Stoyanov2, H. Zlatanov1 1 Military Medical Academy;2Medical Institute, Ministry of Interior, Sofia, Bulgaria Introduction: Cochlear implantation is a routine method for treatment of deafness with proven effectiveness, which has wide application in the developed world. The success of the operation depends on the right patient selection, precise surgical intervention and active postoperative rehabilitation. In the paper are described the main stages and criteria for patients selection. The protocols for setup and postoperative rehabilitation are discussed. Aim: To share our experience in selection and evaluation of cochlear implant candidates. Material: We studied 86 patients, 76 of which children, operated in MMA for the period 2003–2008. Conclusion: For achievement of maximal results from cochlear implantation are essential the joint efforts of highly qualified specialists, parents and pedagogues.

A337 Paraganglioma of the larynx : report of a case A. Benlyazid*, J. Alunni, P. Rochaix Institut Claudius Regaud, Toulouse, France Background: Paragangliomas are neuroendocrine neoplasms most commonly associated in the head and neck region with the carotid body, vagus nerve, jugulotympanic paraganglia, and occasionally the superior and inferior laryngeal paraganglia. Their occurrence in the larynx is rare. They are generally seen as submucosal mass of the supraglottic area. Case report: We present a case of paraganglioma of the larynx seen in a 88 years old female patient with a history of hoarsness for 3 months and difficulties in swallowing for 2 weeks. She has been refered to our institution with a CT scan showing a 36 mm submucosal supraglottic mass. The biopsy previously performed was not informative. The fiberoptic examination showed a submucosal mass of the supraglottic area, bulging under the aryepiglottic fold. A US-guided core needle transcutaneous biopsy allowed the histopathological diagnosis of paraganglioma. After a complete radiologic workup, the patient underwent a submucosal resection of the tumor through an external approach. She had an uneventful postoperative course and remains free of recurrence 6 months after the surgery. Conclusion: Paragangliomas of the larynx are unusual and generally benign neoplasms that must be differentiated from other laryngeal neuroendocrine tumors. Their complete excision is compatible with a submucosal conservative approach. About this case report, clinical, radiologic and pathologic features of this tumor are presented and discussed.

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A339 Phase Out treatment in pure tone and narrow band noise tinnitus patients 1,2

1

1

O. Meeus *, C. Blaivie , K. Heyndrickx , P. Lambrechts1, D. De Ridder3,2, P. Van de Heyning1,2 Withdrawn

A340 Plasma homocysteine and vitamin B12 levels in patients with tinnitus: a retrospective clinical study H. Inancli1*, A. Kutluhan2 1 Ankara Oncology Training and Research Hospital, Ankara, Turkey; 2Ankara Ataturk Training and Research Hospital, Ankara, Turkey Objective: To investigate the possible role of homocysteine and Vitamin B12 on idiopathic tinnitus pathogenesis. Patients and method: 99 tinnitus patients who admitted to our clinic between June 2004 and January 2007 were studied. Patients were divided into 4 groups according to status of accompanying disease and having hearing loss in addition to tinnitus. Group 1 (patients who have an accompanying disease) includes the patients who have diabetes mellitus, hypertension, dyslipidemia, heart, kidney and lung diseases, depression, facial paralysis, thyroid disease, migraine, iron deficiency anemia, tuberculosis, arachnoid cyst together with tinnitus when presenting to our clinic, Group 2; the patients who did not have any accompanying disease, Group 3; the patients who had hearing loss, Group 4; the patients who did not have hearing loss. Plasma levels of homocysteine and vitamin B12 were compared between these groups. Results: 99 tinnitus patients (37 females, 62 males) had ages between 17 and 90 years (mean age 49.48 years ± SD). Forty-three (43.4%) of 99 patients were in Group 1 and 56 (56.5%) were in Group 2. The most frequent accompanying diseases were hypertension, diabetes mellitus (type 2) and dyslipidemia, respectively. 31 (31.3%) patients were in Group 3 and 68 (68.7%) patients were in Group 4. Plasma homocysteine and vitamin B12 levels were compared, we found no statistically significant difference between the groups. Conclusion: Plasma homocysteine and vitamin B12 levels which are thought to play a role in tinnitus etiology were assessed in our study. We could not find any statistically significant difference between four groups.

A341 Polish Universal Neonatal Hearing Screening Program: how we do it? W. Szyfter1*, B. Wiskirska-Woznica3, J. SzyfterHarris3, M. Radziszewska-Konopka2, M. Karlik3, M. Wro´bel1, A. Sekula3 1 Department of Otolaryngology and Oncological Laryngology, Poznan University of Medical Sciences, Poznan, Poland; 2Centrum Zdrowia Dziecka, Warsaw,

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Poland; 3Department of Phoniatrics and Audiology, Poznan University of Medical Sciences, Poznan, Poland Objective: The aim of this study is to share our experience and observations in running the Universal Neonatal Hearing Screening Program on a national level, present results and indicate some problems that have arisen. Methods: The Polish Universal Neonatal Hearing Screening Program started back in 2002 in all neonatal units in Poland. Implemented testing methods consisted of transient evoked otoacoustic emission (TEOAE) performed in all new born children of 2–3 days of life and auditory brainstem response testing (ABR) conducted on children, who did not meet the TEOAE pass criteria. An additional questionnaire registered information on ototoxic drugs and family history of hearing impairment in every newborn. Diagnosed children were further referred for treatment and rehabilitation. Conclusions: Our results indicate the accuracy of newborn hearing screening which remain an issue. Although improvement is needed in both intervention systems and diagnostic follow-up of hospitals, the Polish Universal Neonatal Hearing Program has fully achieved its main goal, the identification and treatment of impaired hearing children.

A342 Preliminary study: comparison of two transient evoked otoacoustic emissions (TEOAE) devices for newborn hearing screening A. Fioretti1*, A. Eibenstein1, G. Soave1, N. Rosati2, M. Fusetti1 1 Surgical Sciences Department, ENT, University of L’Aquila, L’Aquila, Italy; 2Casa di Cura ‘‘Citta` di Roma’’, Rome, Italy Objective: The aim of the study was to compare the results obtained through two different TEOAE devices applying the same screening procedure. Materials and methods: From 2004 to 2006, a first group of 1439 newborns (group A) was evaluated with TEOAE Eclipse device and a second group of 778 newborns (group B) from 2007 to 2008 was evaluated with TEOAE AccuScreen device. For the hearing screening we applied two different three-phases protocols, one for well-babies and one for babies with audiological risk. Results: In the first phase of our protocol we obtained 9% FAIL in the group A and 4% FAIL in the group B. In the second phase were referred 15% of the group A and 2% of the group B. The ABR testing revealed one severe bilateral hearing loss and one monolateral hearing loss in the group A and one monolateral hearing loss in the group B. All three hearing impairments occurred in well-babies. Conclusion: Both the devices lead to an early detection of hearing loss in newborns and can be used for the screening procedure. In the group B we obtained fewer false positives and the number of infants lost during follow-up was smaller. The test with the AccuScreen was faster with a reduced number of FAIL responses because the effectiveness of the test was less influenced by ambient noise contamination. We strongly recommend a universal hearing screening and an effective follow-up in order to early detect a progressive or late-onset hearing impairment.

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A343 Presence and control of micro-organism in external EAR H. Holden1*, P. Drweski2 1 Dispensaire Francais London, London, UK; 2Hopitesux De Paris, Paris, France The appreciation of the environment of the external Ear canal and its control is essential for Hearing Aid users and prevention of external otitis. The various causes and factors with their remedies are discussed.

A344 Scoring system for evaluation ocular-motor disturbances in multiple sclerosis M. Jozefowicz-Korczynska*, A. Pajor Medical University of Lodz, Lodz, Poland Otoneurologic bedside examination and electronystagmographic (ENG) outcome gives valuable information about properties of balance system and may give information about the side of lesion in patients with vertigo, dizziness and disequilibrium. The aim of the study was to present the scheme of otoneurological bedside examination with ocular motor disturbances index and ENG outcome in evaluation of multiple sclerosis patients. Materials and methods: Seventy patients with diagnosis of MS, seen in outpatient neurology clinic, Medical University of Lodz, from 2002 to 2004, were enrolled into the study. Expanded Disability Status Scale (EDSS) scores were evaluated. The clinical bedside ocularmotor examination on the basis of which ocular-motor disturbances index was introduced. The ENG tests like smooth pursuit, optokinetic and saccadic tests, using 4-channel ENG system were performed. Results: MS patients who had in clinical eye movements examination index bigger than 3 point formed the abnormal clinical examination group (ACE)—31.7%. In 68.3% the index was less than normal clinical examination group’ (NCE). The most frequent abnormalities were found in clinical saccadic test in 30% and smooth pursuit in 22% but ENG outcome showed disturbance in saccadic test in 78% and smooth pursuit in 77%. The longer duration of the disease was observed in ACE group. EDSS scores were significantly greater in ACE group. Conclusion: Otoneurological bedside examinations with introducing the ocular motor disturbances index and ENG outcome is a valuable method of evaluation of visual-ocularmotor reflex and may be used in monitoring MS course of disease.

A345 Sensorineural deafness penetrance in A1555G mutation related to European haplogroups A. Garcı´a Arumı´1*, T. Pinos1, M. Mesa3, E. Garcia Arumı´1, A. and reu1, J. Kna¨pper1, E. Ruiz-Pesini2, J. Montoya2, D. Pacheau-Grau2 1 Hospital Universitario Valle de Hebron, Barcelona, Spain; 2Universidad de Zaragoza, Zaragoza, Spain; 3 Hospital de Viladecans, Barcelona, Spain

1131 Introduction: The A1555G mutation in the 12S rRNA gene has been the first mtDNA mutation associated with non syndromic sensorineural deafness. Initially described mainly in subjects who became deaf after aminoglycoside exposure, however, more recently it also has been found in numerous deaf subjects who apparently were never exposed to aminoglycosides. The A1555G mutation has been reported in affected families of different ethnic origin. A hypothetical role of mtDNA haplogroups in disease expression, were investigated in Catalonia, Spanish community. Patients and method: Mitochondrial haplogroups were investigated in 12 different families, with moderate/severe sensorineural hearing loss and A1555G mutation. The mtDNA variation was studied by high-resolution RFLP haplotypes analysis entire mtDNA of each, amplified in nine overlapping fragments by PCR and the primer pairs and sequencing of the control region. Results: We found 9 families haplogroup H, 2 families haplogroup J, and 1 haplogroup HV*. Conclusions: Between the nine European haplogrups: H (45%), V, HV*, J (8–9%) T, U (19%), I, W and X. haplogoup H represented the majority of mtDNA samples of our study (75%). That great penetrance in this specific haplogroup is similar to the reported in other Spanish samples and suggests the mtDNA variants may have a potential modifier role in increasing and expressivity of the deafnessassociated 12S rRNA A1555G mutation.

A346 Special cases diagnosed by DPOAE S. Abdi* Tums, Tehran, Iran Objectives: The aim of this study is to examine a new way to address patients who are complaining of sense of fullness and hearing loss in their ears with normal clinical examinations and hearing test like PTA. These patients did not show any other impairments or abnormality in their Tympanometry, Acoustic Reflexes and ABR. In this study, we used DPOAE in our adult patients feel have hearing problem. The result of it showed that all of these patients have some significant changes in their tests. The idea was to check the function of outer hair cells of inner ear by using Otoacoustic Emission (OAE’s). Methods: 60 enrolled patients were studied for 6 months and examined by Tympanometry, PTA, MCL, UCL, SRT, SDS, ABR, and DPOAE. The time for examination was done at first visit and 6 months later. Results: As a result we could see that only DPOAE showed abnormality and on the other tests we had normal results. (P \ 0.05). Conclusions: DPOAE’s have become a quick and easy way to rule out hearing loss in many difficult cases and it can be used for patients who have some complains of hearing but in the other tests they have normal results. This test can be used for early detection of sensory neural hearing loss.

A347 Suprameatal approach for cochlear implantation: our experience with 436 cases L. Migirov*, J. Kronenberg Department Otolaryngology HNS, Tel Aviv, Israel

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Objective: To demonstrate the advantages of the Suprameatal approach (SMA) in cochlear implant surgery. Materials and methods: A review of the 436 cochlear implantations performed using the SMA between 1999 and 2008 in our department. The SMA involves entering the middle ear by means of retroauricular tympanotomy. A six o’clock vertical incision is made in the meatal skin, and a tympano-meatal flap is elevated to expose the middle ear cavity. The 1–2 mm long groove is then drilled in the middle ear wall postero-superior to the chorda tympani nerve and lateral to the body of the incus. The visualization of the incus body serves as a target for drilling and prevents injury to the facial nerve which is located medially to the incus. After drilling of the cochleostomy and of the suprameatal tunnel, the electrodes are passed through the suprameatal tunnel and groove underneath to the chorda tympani and lateral to the incus into the cochleostomy. Results: There were no surgery-related complications, such as facial nerve palsy, electrode misplacement and damage to the chorda tympani among the children implanted with the SMA. In addition, there were no cases of mastoiditis or subperiosteal abscess since this non-mastoidectomy technique is in use for cochlear implantation in our department. Conclusions: The suprameatal approach shortens the duration of the cochlear implant surgery and allows decreasing the rate of surgery-related complications owing the wide exposure of the middle ear and promontory during cochleostomy drilling and electrode insertion.

Introduction: Basic surgical techniques in the treatment of middle ear cholesteatoma include the intact-canal-wall and canal-wall-down tympanoplasty and combined method, i.e. the ‘‘mobile-bridge’’ tympanoplasty. Techniques including reconstruction of the posterior bone wall of the external auditory canal are combination of formerly mentioned methods. These tympanoplasty procedures involve partial or complete removal of the posterior bone wall of the meatus. Subsequently, after elimination of pathological process, the reconstruction of the middle ear is performed. Materials and methods: 200 patients with middle ear cholesteatoma, who underwent various microsurgery procedures, were monitored and evaluated in the period 1998–2006. The aim of this study was to present the main principles of tympanoplasty and outcomes of middle ear cholesteatoma surgery through a comparative analysis of the applied tympanoplasty techniques. The closed ICW and open CWD tympanoplasty were compared with the combined mobile-bridge technique with reconstruction of the posterior bone wall of the external auditory canal. Results: The incidence values for the recurrent cholesteatoma in closed tympanoplasty and in cases of open techniques with radical trepanation of the temporal bone were 6% and 10%, respectively. In cases of combined mobile-bridge tympanoplasty with reconstruction of the posterior bone wall of the auditory canal the incidence of residual cholesteatoma was 2%. Postoperative rejection of the replanted bone was observed in 2% of the patients. Keywords: Cholesteatoma, Surgical techniques, Tympanoplasty ‘‘mobile-bridge’’, Reconstruction of the posterior bone wall.

A348 Surgery of chronic middle ear inflamations in children

A350 Temporalis fascia graft alterations after wall up tympanoplasty

M. Cosgarea*, A. Maniu, V. Necula, M. Chirila, S. Pop Univerita¨ts HNO klinik, UMF’ Iuliu Hatieganu’, ClujNapoca, Romania Chronic otitis media with or without cholesteatoma in the age of childhood is in this period of very new antibiotic, a difficult problem for ENT specialistes. In children, cholesteatoma of the ear certainly is a much serious problem because frequently shows more expansive and rapid growth than those in adults. Problems involved in the cholesteatoma of the ear in children are concerned with its genesis, a specificity of its development and clinical course,as well as therapy. Extended attico-antromastoidectomy in many cases enables radical operation to be avoided, the cholesteatoma can be removed and reconstruction in one- step or multistage of the sound-conducting apparatus can be performed. In recent years, the children treated with the intact canal wall tympanoplasty appears to have a high rate of recurrence and residual cholesteatoma. However, cavities treated by open technique also have difficulties in the postoperative managements. Therefore the present study (165 cases in 10 years) was carried out to determine whether one method is more preferable than the other.

A349 Techniques end results of surgical treatment cholesteatoma of middle ear D. Dankuc*, L. Vlaski, Z. Komazec ENT Clinic Novi Sad, Clinical Center of Voivodina, Vojvodina, Serbia

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S. Jesic* Institute of Otorhinolaryngology and Maxillofacial Surgery Clinical Centre of Serbia, Belgrade, Serbia Stability of temporalis fascia graft is connected with pathologic process, mucosal status, Eustachian tube function, surgical technique. Objective is to evaluate the incidence of the recurrent perforations and retractions on the temporalis fascia graft after wall up tympanoplasty in 274 adult patients with chronic suppurative otitis, 47 with attic retraction and 50 with traumatic tympanic membrane ruptures. Prospective study of fascia graft status followed up for 2 years by repeated otomicroscopy. The influence of pathologic process, mucosal status, mucociliar transport of Eustachian tube investigated by saharin test were evaluated using Hi square test. The incidence of new perforations was 2% in patients with membrane rupture; 13.9% with suppurative otitis raising with the time (P \ 0.05) and connected with chronic sinus secretion in 76.3% (P \ 0.01). Pars tensa retraction was noticed in 6.57% correlating with the slower mucociliar transport (P \ 0.05). Twenty-four ears with preoperative attic retraction underwent lateral attic wall reconstruction with porous collagen matrix of bovine spongiosa; ten aeration tube insertion alone and thirteen fascia graft alone. There is no recurrence of attic retraction in the reconstructed group, 50.0% with tubes alone and 84.6% with graft alone (P \ 0.01; P \ 0.01). There is no influence of aeration tube insertion in prevention of pars tensa retraction (P [ 0.05) in attic retraction ears. Pathologic process, chronic sinusitis, slower mucociliar transport, deeper mucosal lesions influence recurrent perforation and less pars tensa retraction. Lateral attic wall reconstruction prevents recurrent retraction with more efficacy than aeration tube alone. Keywords: Temporalis fascia graft, Tympanoplasty, Chronic otitis, Retraction pockets

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A351 The evolution of the ‘‘operated ear’s disease’’: what are the causes? V. Sergiu*, A. Andrei, A. Ion, B. Andrei, C. Eduard Department of Otolaryngology, Central Hospital, Kishinev, Republic of Moldova Objective: The cronical medial otitis still remains one of the most important and complicated problem in otolaryngology. In Republic of Moldova aproximately 2.78% of population suffer from this desease; the number of patients increases not only in cases of adult people but in children too. The experience of University Clinic of otorinolaringology, were every year 600–700 patients are cured from the disease metioned earlier, their number constitutes 42% from the total number of interned patients.This fact shows the gravity of cronical middle otitis in our country. Materials and methods: As an example of 77 patients we studied causes why ‘‘opereted ear disease’’ appears. We understood that the illness is caused by the longness of the sickness, the volume of the mastoidal cavity, technical mistakes in radical mastoidectomy, microflora. Outcomes: No matter that ear surgery improved a lot for last 30 years, radical mastoidectomy did not loose it importance. Often appears a type of illness named the ‘‘operated ear disease’’ and the signs of the cronical middle otitis repeat (hearingloss, otorrhoea, headache, vertigo). From 77 cases in 67 was performed a radical mastoidectomy (RM) and in 10-an atticoantrotomy. All patients were reoperated. After RM we restored postsurgical cavity, after atticoantrotomy we performed a RM. In 72 patients we obtained stopping of otorrhoea. The hearing did not suffer significative changes. Conclusions: After our studies about operated ear we concluded that for stopping the illness they have to perform another time a surgery.

A352 The hidden goal of fast phase of vestibular nystagmus: clinical implications A. Katsarkas1, H. Smith1, H. Galiana1

Withdrawn

A353 The influence of haemodialysis treatment in hearing ability C. Makrypides1, E. Gletsou1, E. Theos1, C. Evaggelopoulos1, C. Gantas1, P. Pavlides1, E. Gerostergiou1, M. Apostolidou1*, V. Lachanas1, I. Stefanidis2 1 Otorhinolaryngology, Head and Neck Surgery Department, School of Medicine, University of Thessaly, Larissa, Greece; 2Nephrology Department, School of Medicine, University of Thessaly, Larissa, Greece

1133 Introduction and aims: Sensorineural hearing loss is frequently reported in patients with chronic renal failure undergoing haemodialysis. The role of haemodialysis in the pathogenesis of hearing loss has been a subject of serious debate. Chronic renal insufficiency leads to hearing organ damage due to toxic influence of nitric compounds, electrolyte disorders, anaemia, easiers ototoxic penetration emboli and blood pressure disorders. Methods: In this study 35 patients on maintenance haemodialysis were enrolled (mean age 52.7 ± 14). Serial audiological tests before and after a single session of haemodialysis performed. All tests were repeated after six months. Haematological and biochemical studies, as well as dialysis adequacy (Kt/V) were recorded for all patients. Results: Audiological tests indicated no significant changes before and after a single haemodialysis session. No changes were identified after the 6 months period either. No correlations were found with all parameters recorded. In comparison with the control group, a sensorineural hearing loss in high frequency ranges, especially in 12,000 Hz was noticed (62.8 vs. 15.1% in the control group, P \ 0.01). Moreover, hearing abnormalities in dialysis patients occurred in a younger age (64 ± 13 vs. 64.7 ± 10, P \ 0.05). Conclusion: chronic dialysis patients manifested generally poorer hearing mainly in the high frequency ranges, an index of early hearing impairment. Haemodialysis procedure did not seem to play an important role in the hearing disorders detected here. Decreased clearance of ototoxic drugs, increased incidence of atherosclerosis and hypertension in chronic renal disease could be some of the factors leading to this accelerated presbyacusis.

A354 The outcome of semont maneuver for treatment of benign paroxysmal positional vertigo S. Babac1*, Z. Ivankovic´1, R. Kosanovic´1, M. Petrovic´-Lazic´1, V. Stojanovic´ Kamberovic´2, M. Tatovic´1 1 ENT Clinic Zvezdara Clinical and Hospital Centre, Belgrade, Serbia; 2Zvezdara Health Centre, Belgrade, Serbia Benign paroxysmal positional vertigo of the posterior canal (PCBPPV) is a common vestibular disorder and can be easily treated with Semont maneuver. Objectives: To assess the efficacy of Semont maneuver in our clinic in the treatment of the benign paroxysmal positional vertigo of the posterior semicircular canal (PC-BPPV) and to establish any characteristic features of cases of treatment failure. Methods: The efficacy of Semont maneuver was compared with a sham procedure in 66 patients with PC-BPPV. Patients were randomly assigned to treatment with Semont maneuver (n = 36) or a sham procedure (n = 30). Results: Seven days after treatment 89% of patients in the Semont maneuver group had neither vertigo nor nystagmus on positional testing compared with 9% of patients in the sham group (P \ 0.01). After second Semont maneuver recovery rate was 92.7. While 29 out of 36 patients treated with Semont manoeuvre were diagnosed with idiopathic BPPV, in 7 patients secondary BPPV was determined. The etiology of p-BPPV had a significant effect on the maneuver’s success rate (P \ 0.01), whereas duration of symptoms (P [ 0.05), age (P [ 0.05) and gender (P [ 0.05) had no effect. Conclusion: Semont maneuver is shown to resolve PC-BPPV both effectively and rapidly. Patients with idiopathic PC-BPPV showed higher success rate with Semont maneuver than those with secondary

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1134 PC-BPPV. Patients with secondary BPPV may have quantitatively or qualitatively different lesions than those with idiopathic BPPV. Keywords: Benign paroxysmal positional vertigo, Etiology, Treatment, Semont maneuver

A355 The program of newborn hearing screening: our experience D. Vranjes*, S. Spiric, P. Spiric, Z. Novakovic, A. Aleksic ENT Clinic, Clinical Centre Banjaluka, BanjaLuka, Bosnia and Herzegovina There are two categories of early diagnostic procedures of newborn hearing impairment: universal newborn hearing screening and screening in groups at risk of hearing impairment. The battery of screening tests is consisted of: transient evoked otoacoustic emissions—TEOAE, distorsion product otoacoustic emissions—DPOAE, automated audiotory brainstem responses- AABR, steady state auditory evoked potentials—SSAEP. In our Clinical Center TEOAE is compulsory test for newborn population in general. The universal program of newborn hearing screening (90% tested by TEOAE + AABR) was calculating as giving almost 100% sensitivity and 90% specificity. The program of newborn hearing screening in RS began in our Clinical Center from 1 April 2004. By decision of Ministry of Health of RS and Fund for Health Insurance, this program is compulsory in all Regional Hospitals. In a 4 year period in Clinical Center Banjaluka 11,874 newborns has been tested by TEOAE and 1,387 newborns by AABR screening method. 39 of these children underwent ABR testing and frequency specific hrabrenje under general anesthesia. The youngest children underwent the procedure were 5 months old. Lack of education of medical professionals and establishing of an unique data-base for BiH is still very important obstacle in our work. In order to continue our work and improve the quality of our procedures, the program has to be supported by Government and Ministry of Health. Well equipped centers, educated medical professionals, informed and cooperative parents are the elements of crucial importance for this screening program conduction.

A356 The relationship of homocysteine, vitamin B12, folic acid and vertigo E. Aydin, S. Turkoglu Babakurban*, O. Ozgirgin, L. Ozluoglu Department of Otorhinolaryngology, Baskent University Faculty of Medicine, Ankara, Turkey Objective: The aim of this study was to investigate the association between serum homocysteine, vitamin B12 and folic acid levels and vertigo in the patients who were referred to our department because of peripheral vestibular dysfunction. Background: The detailed etiopathogenesis of vertigo still remains unknown. Vestibular functions can be adversely effected from metabolic changes which are related with hemostasis. Hyperhomocysteinemia and vitamin B12, folic acid defciency can be considered to reflect the vestibular dysfunction by affecting the hemostasis.

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Methods: 41 patients (mean ± SD age = 57.34 ± 14.293) who were referred to our clinic with vertigo were prospectively assessed with audio-vestibular tests, serum homocysteine, vitamin B12 and folic acid measurements were completed before treatment. We investigated the relationship between the serum homocysteine, vitamin B12, folic acid level and peripheral vestibular dysfunction. Results: 29.3, 36.6, and 34.1% of the patients were diagnosed as Meniere’s disease, vestibular neurinitis, and benign paroxysmal positional vertigo respectively. Homocysteine (12.42 ± 3.56 vs. 11.32 ± 4.14 vs. 10.72 ± 2.95 umol/l, P [ 0.05), vitamin B12 (371.58 ± 141.35 vs. 288.13 ± 139.51 vs. 352.14 ± 150.41 pg/ml, P [ 0.05) and folic acid (8.76 ± 3.2 vs. 10.63 ± 6.59 vs. 8.8 ± 3.18 umol/l, P [ 0.05) values were similar in all of the groups as compared to each other. Conclusion: This is the first prospective study investigating the relation between serum homocystein, vitamin B12 and folic acid levels with vertigo. In this study we found that there is no correlation between homocysteine, vitamin B12, folic acid levels and peripheral vestibular dysfunction.

A357 The role of diet therapy in patients with Presbyacusis S. Varbanova1*, D. Popova, D. Popova 1 Sofia, Bulgaria Objective: The increased life expectancy turns the attention to problems associated with ageing in all organs and systems of the human organism. The authors review the change in the functional capacity of the hearing analyzer in its peripheral and central components in the process of ageing. The aim of this study is to track the effect of diet therapy on hearing loss, tinnitus and comprehension by virtue of hearing aids. Materials and methods: The patients analyzed are of ages from 70 to 85 years. Over the course of 4 months, they were treated with Omega-3 polyunsaturated acid fat, coenzyme Q-10, gama linoleic acid and vitamin D in certain proportions. The patients were tested before and after conception for: biochemical and nutritional status, mini-mental state examination, hearing tests, including subjective and objective measurements. Results: The elderly subjects, whose condition was evaluated following a period of 4 months of treatment, showed improvements in pure tone audiometry for the greater part, as well as improved comprehension of speech audiometry. Those using hearing aids showed improvements in comprehension and better language communication resulting in greater self esteem. Conclusion: We consider that the use of diet therapy as a treatment option for influencing the effects of presbyacusis (hearing loss and tinnitus) is successful through changes in the cognitive and memory capabilities of patients over the age of 70. The marked improvement of speech comprehension, especially with the assistance of a hearing aid, leads to a higher quality of life.

A358 The Vibrant-Soundbridge as active PORP and TORP W. Hohenhorst*, S. Schro¨der, A. Park Kliniken St. Antonius, Wuppertal, Germany

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Objectives: The Vibrant Soundbridge as a semiimplantable heraing aid is usually implanted with the floating mass transducer attached to the long process of the incus. It also can be placed in a defect ossicular chain as an active PORP or TORP. We describe the results from a 4 year period in implanting the system as an active PORP and active TORP. Method: In 2005 and 2006 four patients with severe mixed hearing loss have been implanted with the VSB into a defect ossicular chain. All patients had previous middleear surgery and suffered from severe mixed hearing loss. The FMT was placed as a PORP onto the stapes. In all cases an endaural approach was performed. The FMT was integrated into a palisade cartilage tympanoplasty according to Heermann. Results: All patients were satisfied and no complications occurred. The VSB as PORP improved conductive thresholds up to 35 dB. The aided threshold in all patients was less than 30 dB. The unaided preoperative threshold was 50–80 dB. Conclusion: The VSB implanted as an active PORP in defect ossicular chains is an effective option for patients with severe mixed hearing loss. A palisade cartilage tympanoplasty provides optimal surgical preconditions.

A359 Tinnitus retraining therapy in Slovakia L. Suchova* Phoniatric Department, University Hospital Bratislava, Bratislava, Slovakia The aim was to evaluate the effect of TRT in processing the anamnestic data and semiobjective and objective examination results in patients before treatment and after 6 month therapy. Patients and method: Since Mai 1999 Tinnitus Retraining Therapy (TRT) has been used in the management of 300 patients (132 men, 168 women) with tinnitus of various origin in our out patient tinnitus treatment department, which is the first in Slovakia. Result: After 6 months of continuous therapy 77% patients reported improvement of tinnitus or it has disappeared. In semiobjective examination of Feldmann tinnitus masking curves tinnitus improvement was established in 38% right ears and 44% left ears. Discussion and conclusion: Considering these findings, it would appear TRT can be useful for extending the possibilities of tinnitus treatment in Slovakia. The subjective patient0 s evaluation is more important then the semiobjective examination result in establishment of TRT effect.

A360 Treatment with prednisolone or acyclovir in Bell’s palsy E. Gerostergiou1, I. Tsitiridis1, V. Lachanas2*, G. Karatzias1, E. Gletsou2, M. Chorti3, C. Makrypidis2, Z. Bessas3, I. Papagiannis3, T. Kaffes3 1 Audiology Department, General Hospital of Larisa, Larissa, Greece; 2Otorhinolaryngology, Head and Neck Surgery Department University of Thessaly, School of Medicine, Larissa, Greece; 3ENT Department, General Hospital of Karditsa, Karditsa, Greece

1135 Objective: Bell’s palsy is acute, idiopathic paralysis of facial nerve. Vascular inflammatories and viral causes have been suggested from paired serologic analyses. Epidemiologic studies show that 20 to 30 persons per 100,000 are affected each year, most commonly between ages of 30 to 45 years. In this survey we tried to determine the effectiveness of steroids and acyclovir in Bell’s palsy. Method: 77 patients suffering from Bell’s palsy were studied. All of them underwent otoscopy, tympanometry, reflex decay test and electroneurography. Patients in group A (52) were hospitalised and treated with intravenous administration of prednisone and oral administration of valaciclovir, and compared with group B (33) who were treated only with valaciclovir and vitamins (orally) (without corticoids) because of other diseases (ulcer gastric, hypertension, diabetes mellitus). 3 patients with partial facial palsy denied treatment. Results: 46 (54.5%) of the patients were male and 39 (45.5%) female. The recovery rate in patients in group A, treated with the combination of valaciclovir and prednisone, was 100%. The corresponding rate in patients in group B, treated with valaciclovir and vitamins, was only 71.38%. 2 of the patients who denied treatment recovered fully, while the third one still suffers from facial palsy grade II. Conclusions: Necessary medicines seem to be the corticoids. That’s why we must always take under consideration their administration, even when they are contraindicated, in close cooperation with other medical specialities in order to prevent possible complications. Male and female in our study are equally affected by Bell’s palsy.

A361 Universal new born hearing screening program in KFMMC hospital S. Al-Saif1*, M. AbdelTawwab2* 1 ENT Department, King Fahd Military Medical Complex, Dhahran, Saudi Arabia; 2ENT Department, Mansoura University, Egypt Objectives: The purpose of this study was to establish universal newborn hearing screening (UNHS) program in King Fahd Military Medical Complex (KFMMC) hospital and to study the prevalence of hearing loss in neonates delivered in this hospital. Subjects and methods: All neonates delivered normally or by cesarean section in KFMMC from 15 April 2003 to 1 August 2006 were screened for hearing impairment by OAEs then ABR. Results: A total of (2,592) neonates were screened for hearing loss. The prevalence of hearing loss was 0.98% in both ears, 51 out of 5,184 ears have hearing loss. 29 (1.1%) newborn had hearing loss of various degrees, 22 of them were bilateral and 7 newborn had unilateral hearing loss. Discussion and conclusion: The prevalence of hearing loss in our medical facility is 11 out of 1,000 newborn suffer from hearing loss of various degrees. From this study we concluded that it is important to make the public aware of the value and importance of hearing screening at the earliest possible opportunity also UNHS should be made mandatory in order to allow for early detection and management of hearing loss. Keywords: Universal Newborn Hearing Screening, UNHS, Transient evoked otoacoustic emissions, TEOAEs, Auditory brain stem response, ABR, Hearing loss.

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A362 Vestibular disorders, objectively proved by videonystagmography in patients with metabolic syndrome Z. Zhelyazkova* EAONO Member, Sofia, Bulgaria Metabolic syndrome is a name for a group of symptoms that occur together and promote the development of type 2 diabetes/insulin resistant/obesity/cholesterol abnormalities, and hypertension. Systemic metabolic diseases including as well hyper- and hypothyroidism lead to disturbances of the function of the inner ear. The aim of the study is to observe whether there are any hearing loss and vestibular disorders in patients, suffering from different metabolic diseases and to clarify the necessity of neurootological examination and complex treatment of patients with vestibular disorders and metabolic diseases. The study was performed at the Department of Neurootology, ENT clinic—in the Medical Institute—Ministry of Interior, Sofia for a period of 3 years. All the patients signed inform consent and the study was approved by the Local Ethic Committee. 104 patients with the following metabolic diseases: hyperthyroidism, hypothyroidism, hypertension, diabetes mellitus-type 2/insulin resistant and obesity were enrolled in the study. The patients passed precise otorhinolaryngological and neurotological examination, including videonystagmography and posturography, stato-kinetic tests; standard pure tone audiometry, auditory evoked potentials, before and after the treatment. All the patients complained of vertigo, unsteadiness and neuro-vegetative symptoms. The patients of different groups of diseases exposed different symptoms of vestibular disorders, such as: nystagmus, unsteadiness, nausea. The symptoms were systematized in tables before and after the complex 3-monthly treatment by endocrinologist and neurotologist. We recommend complex neurootologic and endocrinologic examination and treatment of the patients with vestibular disturbances, suffering from metabolic syndrome or metabolic diseases.

A363 Vestibular evocated myogenic potentials (VEMPs) and benign paroxysmal positional vertigo (BPPV) A. Garcı´a Arumı´*, T. Minoves, D. Moncho, M. Navarrete, R. Boemo, R. Wegmann, K. Breitenbu¨cher Hospital Universitario Valle De Hebron, Barcelona, Spain Introduction: VEMPs testing are one of the most recent of innovations to the clinical vestibular testing. The VEMP pathway has been speculated to include the saccule, inferior vestibular nerve, vestibular nucleus, and medial and lateral vestibulospinal tract to the ipsilateral sternocleidomastoid muscle. The VEMP response has been clinically investigated in several pathological conditions, including acoustic neuromas, vestibular neuronitis, Meniere’s disease, sensorineural hearing loss, multiple sclerosis, and superior canal dehiscence syndrome, but little has been reported in posterior canalolithiasis BPPV especially comparing with caloric testing VNG results, aim of our study. Patients and methods: Caloric and VEMP responses were tested after treatment, relief of vertigo and findings of negative positioning maneuvers in 15 patients diagnosed with idiopathic posterior canalolithiasis BPPV (10 left, 2 right, 3 bilateral). Ipsilateral and contralateral VEMP thresholds, ipsilateral p13 and n23 latencies at

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 105 dB, inter-peak amplitude and the interaural amplitude difference were determined, and compared with our control group. Results: We found that VEMP latencies are increased in 8 patients (6 left, 1 right, 1 bilateral) one of them with also abnormal caloric responses (1 left). 3 patients with abnormal caloric responses (3 left) showed normal VEMPs. Conclusions: Saccular compromise measured by VEMPS seems to be quiet frequent in our patients, that suggests that the degenerative process might affect the macula of the saccule and the saccular nerve also, but caloric responses, horizontal canal disfunction, doesn0 t correlates with them.

A364 Vibroplasty through direct stimulation of the round window membrane: surgical procedure and outcomes in patients H. Skarzynski, R. Podskarbi-Fayette* Institute of Physiology and Pathology of Hearing, Poland Middle ear implants have become a new prosthetic device for those patients who could not benefit from other amplifying aids. Vibroplasty, can significantly increase comfort and quality of life in these patients. Since Introduction of MEIs in treatment of conductive hearing loss indications for vibroplasty have expanded and now include cases of sensorineural and mixed hearing losses. In the later indications the vibrating component of the active middle ear implant (transducer) is placed in the round window niche. Since Introduction of this method in 2002 surgical procedure has evolved, especially in the way the surface of the transducer is isolated from the round window membrane. Thickness of fascia tissue recommended for placement over the membrane has been reduced to 0.1 to 0.2 mm. Our Center, since the method of round window placement of the transducer was introduced (2004), has used a unique method of ‘‘direct stimulation’’ of the round window membrane. The basis for procedure include meticulous preparation of a pocket in the round window niche that is slightly larger than the device. The principle is to allow free vibratory motion of the FMT seated in the niche without undue compression of a convex round window membrane. Post operative observations indicate that encapsulating the FMT entirely may contribute to loss of vibratory energy. Also, stimulation may not be as efficient if the transducer lies freely in the proximity of the round window membrane. Outcomes in patients following vibroplasty with direct stimulation of the round window membrane were presented and discussed.

RHINOLOGY

A365 A comparative study of brain perfusion single photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI) in patients with post traumatic anosmia S. Atighechi*, H. Salari, M. Baradaranfar, R. Jafari, Z. Ansari Yazd, Iran

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Introduction: Loss of smell is a problem that can occur in up to 30% of patients with head trauma. The olfactory function investigation methods so far in use have mostly relied on subjective responses given by patients. Recently, some studies have employed MRI and SPECT to evaluate patients with post traumatic anosmia. The present study seeks to detect post traumatic anosmia as well as the areas in the brain that are related to olfactory impairment by using SPECT and MRI as imaging techniques. Materials and methods: The study was conducted on 21 patients suffering from head trauma and consequently anosmia as defined by Cain’s identification test. They all had fulfilled the procedure requirements already. Two control groups (traumatic normosmic and nontraumatic healthy individuals) were selected. Brains MRI, qualitative and semi-quantitative SPECT were taken from all the patients. Then the brain SPECT and MRI were compared with each other. Results semi-quantitative assessment of the brain perfusion SPECT revealed frontal, left parietal, and left temporal hypoperfusion as compared with the two control groups. 85% of the anosmic patients had abnormal brain MRI. Regarding the MRI, the main abnormality proved to be in the anterior inferior of the frontal lobes and olfactory bulbs. Conclusion: The findings of this study suggest that damages to the frontal lobes and olfactory bulbs as shown in the brain MRI and hypo perfusion in the frontal, left parietal and left temporal lobes in the semi-quantitative SPECT corresponds to post traumatic anosmia, further neurophysiological and imaging studies are needed.

A366 A review of ethiopathogenesis of nasal and paranasal cavity poyps M. Zivic* ENT Department, School of Medicine, Nis, Serbia Histologically polyps can surely be divided in the following types and it is recommended to put the approximate percentage of frequency: fibromatosic (80%), adenomatosic (15%) and angiomarosic (5%). Ethiopathogenesis of nasal polyps and paranasal caves is multifactorial (they do not have the same ethiolgy) and according to our opinion, they can have the following origin: a) tumors-like (angiomatosic, adenomatosic and fibromatosic), b) no allergic inflammatory and c) allergo-inflamatory. Cytic dilatation of ductus and lumen glands,as secondary change with mostly acidic mucilage, take a great part of the capacity of polyps in most cases. Edematization affirms that there are immunological conflicts so the nasal polyp is most frequently further stimulated by that which makes enlarge its capacity or deepens the inflammatory as circulus viciosus. Introduction of therm edematized polyps does not respond the truth, because it is about the accompanyng phenomna.

A367 Aberrant internal carotid artery: recurrent bleeding emergencies after routine paracentesis G. Tzamalis*, A. Albers ENT Department, Charite Benjamin Franklin Berlin, Berlin, Germany

1137 Background: The ectopic transtympanic course of the internal carotid artery and the anomalous carotid anatomic pattern with a persistent stapedial artery as vascular anomalies are described in the literature. Case: We report about a 46 years old female patient who was admitted to our clinic with a massive otorrhagia from the right ear and bleeding from the nose and mouth. The paracentesis was performe as an outpatient procedure to treat the symptoms of a persistent serotympanon. The bleeding stopped spontaneously after controlling the blood pressure and placing the patient upright. Otoscopy showed a hematotympanon and bleeding through the tympanic membrane. Further ENT examination revealed no pathological findings. MRI and angiography showed an aberrant course of internal carotic artery in the squamous part of the temporal bone with a short constricted segment behind the injury. The following week another spontaneous bleeding event occurred which was also stopped by conservative measures. Interventional therapy was discussed with the patient but, following her wish none of these were performed. Lifelong follow-up was advised. Conclusion: Alterations of the tympanic membrane can imitate or mask aberrant vessels in the middle ear. To prevent injury of theses vessels, a paracentesis should only performed with a sickle knife, never with a lancet. In cases where a bluish-red formation behind the tympanic membrane is seen combined with the symptoms of pulsatile tinnitus and conductive hearing loss, a vascular malformation should be suspected and imaging of the temporal bone should precede any intervention.

A368 Abscess of the orbit as a complication of a acute sinusitis: double surgical approach U. Bolinaga*, N. Perez*, R. Lobato*, P. Martinez Seijas, E. Perez Samitier, M. Abrego, J. Algaba Hospital Donostia San Sebastian, Spain Objectives: We present the double surgical approach, sinus endoscopic surgery and external decompression of a youth who presented an abscess of the orbit due to an acute sinusitis. Materials and methods: 14 years old male came to our department with a orbital cellulitis, proptosis and severe limitation of the eye movement and diplopia. Previously he suffered an acute sinusitis. The CT scan shown a soft-tissue inflammatory changes, between the superior and external region of the orbit and total occupation of the maxillary, frontal and ethmoidal sinus The surgical management of the orbit was done by endoscopic sinus surgery with ethmoidectomy and maxillary meatotomy. Simultaneously we realized a Lynch external drainage of the orbit, with a subperiosteal dissection; after that a soft corrugated drainage was placed. Discussion: Orbital complications of sinusitis are most often attributable to the ethmoid sinuses, though 84% of cases have radiographic evidence of disease involving two or more sinuses Preseptal cellulitis (group I) is treated empirically with broad-spectrum intravenous antibiotics Chandler groups II (orbital cellulitis) and III (subperiostealabscess) are treated endoscopically;however, when inflammation precludes adequate drainage of the orbital infection, or ventilation of the involved sinuses, external techniques may be employed. Conclusions: Surgery is recommended if any one of the following four indications is met: CT evidence of abscess formation, decreased visual, severe orbital complications on initial presentation with ipsilateral sinusitis (blindness, afferent papillary reflex, ophthalmoplegia)

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or progression of symptoms or failure to improve during the first 48 h with appropriate medical treatment.

A369 Acustic rhinometry in children L. Haavisto*, J. Sipila¨ Department of Otorhinolaryngol, Head and Neck Surgery, Turku University Central Hospital, Turku, Finland Since acoustic rhinometry was described there has been a lack of normal values for minimal cross-sectional area (MCA), especially for children. There has also been debate about factors influencing normal values. The purpose of this study was to find out whether there is any correlation between age or body surface area and minimal crosssectional area. Another purposes was to get more practice in measuring children and to find a reliable way to use acoustic rhinometry. We measured 74 children (age 1–12 years) with an acoustic rhinometer. The values of MCA were compared with age and body surface area determined from height and weight. The mean of unilateral MCA was 0.225 cm2 (SD 0.041). We found positive correlation between unilateral volume on the left side and age, and between MCA from the right side and age or body surface area as a constant predictor. As much as 28.4% of the measurements had to be rejected because of acoustic leakage between nostril and nosepiece. Only 6.8% had to be rejected because of a lack of co-operation. It is possible to find normal values for children. Acoustic rhinometry is well tolerated among children. The method is rapid, reliable and noninvasive, and minimal co-operation is required. The measurements must be done in a standard way, and some important causes of errors must be kept in mind. Further study is needed to determine reference values for children in Finnish population.

A370 Advantages of argon plasma coagulator in FESS M. Kendric*, M. Kendric, B. Janjetov General Hospital Sremska Mitrovica, Serbia Introduction: The aim of this study is to compare the effects of using Argon plasma coagulator (APC) as new technique for FESS and traditional technique. Materials and methods: We compared two techniques: Argon plasma coagulator (APC+) and traditional (APC-) by incidence of: postoperative synechiae, recurrence of inferior turbinate hypertrophy and recurrence of polyps. During the last 2 years two group of patients were included in this prospective randomised study. Group APC+ of 50 patients aged 36 ± 6.6 operated with Argon plasma coagulator and APC- group of 51 patients operated using traditional technique aged 39 ± 7.1. Postoperative follow up was performed after first, second week and after that monthly during 2 years. Statistics were analyzed with Chi-Squared test and Student T test. Results

Synechiae

Rec. hypertrophy

APC+

0

0

2

APC2 P value \ 0.05

5

3

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Rec. polyps

Conclusion: Recurrence of inferior turbinate hypertrophy, recurrence of polyps and incidence of synechiae were lower but not significantly. Number of complications was significantly lower in APC+ group.

A371 Analgesia in anterior epistaxis treated with silver nitrate cautery S. Vyas*, H. Zeitoun, J. Osbourne, Z. Hammad Glan Clwyd Hospital, Rhyl, LL18 5RG, UK Objectives: Recurrent, anterior epistaxis is a common condition seen by G.P’s, A + E, and ENT departments. In order to prevent pain, lidocain spray (a local anaesthetic) is commonly used in the nostril, topically, prior to the application of cautery. This is often insufficient as we have previously shown that there is still considerable patient discomfort. Here an attempt is made to assess if oral analgesia makes any difference. Methods: 140 (72 males, 68 females, 42 children) patients were involved. These were patients that had minor, anterior, recurrent epistaxis seen in the clinic. Oral analgesia in the form of paracetamol, was prescribed about half an hour prior to treatment. Thorough history and examinations were performed, and once the source identified in the anterior nostril, lidocaine nasal spray was applied. Then the treatment was completed with silver nitrate cautery. Patients were then asked to fill in a pain score immediately, and after 30 min in the form of a visual analogue scale (VAS) 1, (least pain) to 10 (highest pain). Results: Immediately after the silver nitrate application: For adults (98): 55 (56.1%), 3–5 on VAS 29 (29.6%), 5–7 on VAS 14 (14.3%), 7–9 on VAS For children (42): 27 (64.3%), 3–5 on VAS 10 (23.8%), 5–7 on VAS 5 (11.9%), 7–9 on VAS 30 min after silver nitrate application, 9 adults (9.2%) and 3 children (7.1%) report 3-5 on VAS. Conclusions: For the treatment of anterior epistaxis, with silver nitrate cautery, both lidocaine spray and oral analgesia should be used.

A372 Anosmia: what was the cause? A. Obando1*, I. Alobid1*, F. Gasto´n2, J. Mullol3 1 Unitat de Rinologia-Clı´nica de L’Olfacte, Servei d’OtoRino-Laringologia, Hospital Clı´nic I Universitari; 2Servei de Neurocirugı´a, Hospital Clı´nic I Universitari, 3IDIBAPS, IRCE, San Jose, Costa Rica Introduction: Olfactory dysfunction is common in the general population, hyposmia affecting 16–19% an anosmia 0.5–2%. More than 200 conditions have been associated with the loss of the sense of smell. However, three are the most common causes: sinonasal inflammatory diseases, head trauma, and viral upper respiratory tract infection (URTI). Case study: We report a case of a 43-year-old woman who came to our Rhinology Unit and Smell Clinic complaining of persistent anosmia that suddenly appeared after three episodes of viral URTI. After a normal nasal endoscopic examination, anosmia was confirmed by subjective olfactometry (BAST-24). The CT scan showed no pathology in the paranasal sinuses while some osteolitic changes were observed in the frontal bone. Further imaging study with MRI demonstrated a giant olfactory grove meningioma. The tumour was surgically resected by craniotomy without further complications. The patient remains without recurrence 2 years after surgery.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Conclusions: Post-URTI olfactory dysfunction accounts for 22 to 42.5% of causes in different series. It is more common in women over 50 years of age, which complain of sudden loss of smell after an URTI that persisted when the infection resolved. Intracraneal tumours, specially meningiomas of the midline anterior skull base, are rare causes of smell disorders. The learning message to take home from this case is that hyposmia and anosmia are prevalent symptoms that always must be further studied since more than one cause may be responsible for the loss of smell.

A373 Approaches towards topical therapy of rhinosinusitis using pulsating aerosols W. Mo¨ller1*, U. Schuschnig2, G. Meyer3, K. Ha¨ußinger4, H. Mentzel2, M. Keller2 1 Clinical Cooperation Group Inflammatory Lung Diseases, Helmholtz Zentrum Mu¨nchen, Gauting, Germany; 2Pari GmbH, Mu¨nchen and Starnberg, Germany; 3Department of Nuclear Medicine, Asklepios Hospital Mu¨nchen-Gauting, Gauting, Germany; 4Department of Pulmonary Medicine, Asklepios Hospital Mu¨nchen-Gauting, Gauting, Germany Rationale: Although there is a high incidence of nasal disorders including chronic sinusitis, there is limited success in topical drug delivery to the nose and the paranasal cavities/sinuses. This is caused by the nose being an efficient filter for inhaled aerosol particles and the paranasal sinuses being virtually non ventilated. Objectives: The objective of this study was to visualize the efficiency of sinus ventilation in a human nasal cast and in three healthy human volunteers using dynamic 81mKr-gas gamma camera imaging in combination with pulsating airflows. Furthermore, the efficiency of deposition and retention of 99mTc-DTPA radiolabelled aerosol was assessed. Results: In the nasal cast ventilation efficiency of the sinuses was increased more than fivefold and aerosol deposition more than twentyfold compared to a delivery regime without pulsation. Up to 8% of the nebulized drug was deposited into the paranasal sinuses of the nasal cast whereas only 0.2% deposition was achieved without pulsation. Efficient ventilation of the paranasal sinuses was confirmed in human healthy volunteers applying a pulsating airflow and this was associated with a drug deposition of up to 5%. Surprisingly, clearance kinetics of the drug was reduced and associated with an up to twofold longer residence time of the drug at the site of deposition. Conclusions: Our data support the hypothesis that topical drug delivery in relevant quantities to the nose and osteomeatal areas, including paranasal sinuses, is possible using pulsating airflows. Furthermore, due to a delayed clearance, the frequency of drug applications can be reduced.

A374 Aspergillus fumigatus in chronic rhinosinusitis with nasal polyposis M. Krajinoviæ1*, L. Janosˇeviæ2, I. Penðer2, M. Zˇivkoviæ1, V. Ðukiæ2 1 Medical School University of Belgrade, Belgrade, Serbia; 2 Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, Belgrade, Serbia

1139 Introduction: Patients with nasal polyposis appear repeatly in otorhinolaryngology practice. The exact etiologic mechanisms leading to the formation of nasal polyps have remained largely unclear, so most scientists today stand at the point that nasal polyposis is a multifactoral disease. Fungal organisms were suspected to be the causative agents of CRS with/without nasal polyposis as inflammatory and/or immunological factors. Objectives: We designed a study to investigate a frequency of Aspergillus fumigatus (A.f.) in sinus secretions and sera specimens from patients who were undergoing FESS for CRS with nasal polyposis. Method: Prospective study. Forty (40) patients with diagnosis of CRS with nasal polyposis underwent FESS, performed by experienced surgeon. Specimens of mucin secretions obtained intraoperatively from maxillary sinus after polyp removal, were sent to the laboratory of Clinical Center of Serbia and plated on Sabouraud dextrose plates. The serum of patients were examined for specific IgE to A.f. and ECP by using UNI CAP 100 System, Pharmacy, Uppsala, Sweden. Results: We were able to demonstrate the presence of A.f. in 2/40 (5%) of sinus secretion intraoperative specimens. One (2.5%) of those two patients had elevated specific IgE to A.f. while the serum samples of remaining 39 patients were negative. The serum ECP was elevated in 19/40 (47.5%) mean value 19.6. Conclusions: Using standard laboratory techniques detection of A.f. in maxillary sinus is rare, but immunological responses to this fungus asserted in this study indicate it as possible pathogenic factor. More precise diagnostic tools are necessary to prove those findings.

A375 Association between epistaxis and hypertension S. Vyas*, R. Singh Crosshouse Hospital, Kilmarnock, UK Objectives: There is a continuous debate about hypertension and epistaxis. Our aim was to assess: 1. The relationship of hypertension with epistaxis. 2. Use of short and long term antihypertensives to see if it made any difference to epistaxis. 3. If any surgical intervention was required. Methods: 210 (120 males, 90 females), age ranges 24–88 years, with epistaxis were studied retrospectively. Their average blood pressure recordings on admission and during their stay were noted. Furthermore, the number of episodes of epistaxis despite any antihypertensive and/or surgical treatment were noted. The patients were then followed up to 1 year post-discharge, to assess if there was any further epistaxis with appropriate antihypertensive treatment. Results: 126 (60%) patients had high BP [ or = 140/90. Out of these 1. 101 (80%) had sustained BP during their stay. 2. 82 (65%) were already on some kind of antihypertensive treatment prior to admission. The remaining 44 (35%) were unaware of their hypertension. Out of this, 38 (38%), ended up on oral antihypertensive treatment in the next year. 3. 11 (9%) of these required further or different antihypertensive therapy. 4. 3 (2%) required some form of surgical intervention. 5. 8 (65) were re-admitted within 1 year with recurrent epistaxis. Conclusions: A significant number of patients (126, 60%) with epistaxis have hypertension. Majority of these (101, 80%), have sustained high BP. Commencement of antihypertensive treatment

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1140 during and post-discharge, reduced the risk of epistaxis long-term up to 1 year.

A376 Association between single-nucleotide polymorphisms in SP-D and allergic rhinitis in Chinese patients T. Zezhang1*, D. Yuqin*, K. Yonggang, X. Bokui, X. Yu 1 Renmin Hospital of Wuhan University, Wuhan, China The development of allergic rhinitis is considered to be determined by the interaction between genetic and environmental factors. Surfactant protein D (SP-D) has been proposed to offer protection against allergenic challenge at various levels in allergic responses. The present study aimed to investigate whether polymorphisms within the SFTPD gene (Met11Thr, Ala160Thr, and Ser270Thr) are associated with allergic rhinitis. Genotyping of SFTPD polymorphisms was performed using the pyrosequencing method. The study population comprised 216 patients with allergic rhinitis and 84 normal controls. The frequency of genotype 11Thr/Thr and allele Thr in the patient group was significantly higher than that in the control group after applying Bonferroni corrections (P = 0.007 and P = 0.006, respectively). Our subjects with the 11Thr/Thr genotype are more susceptible to allergic rhinitis. There were no significant differences between the patient group and the control group for frequencies of genotypes and alleles in either Ala160Thr or Ser270Thr SNPs (P [ 0.05). No significant associations could be detected between any of these three SFTPD gene polymorphisms and the skin-prick test response (P [ 0.05). Meanwhile, there was a lack of association between the three loci and the levels of serum total IgE (P [ 0.05). In summary, our results suggest that the Met11Thr polymorphism in SP-D plays a major role in the genetic predisposition to allergic rhinitis in Chinese adult population, whereas the other two SP-D polymorphisms displayed no significant association with allergic rhinitis.

A377 Benign isolated sphenoid lesion: diagnosis and management M. Elsayed* Ahmed Maher Teaching Hospital, Cairo, Egypt Introduction: Cases of isolated benign lesions of the sphenoid sinus are rare. For descriptive purposes, clinicians divide them into inflammatory and non-inflammatory with prevalence of the former. Symptoms of the sphenoid sinus disease are difficult to characterise, the most common of them being vague headache and visual disturbances. Thorough preoperative evaluation of the lesion is essential—nasal endoscopy must be performed and computerised tomography or magnetic resonance imaging results analysed. The purpose of the study is to present the assessment of endoscopic surgery outcome in the group of patients with isolated sphenoid disease. Materials and methods: Clinical data of 21 subjects were analysed retrospectively. Female to male ratio is 2:1 with age range between 15 and 58 years old. There were10 patients with bacterial sinusitis, 6 with fungal sinusitis, 2 with allergic thickening of the mucous

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 membrane with no evidence of bacterial or fungal infection, 2 with mucocele, and 1 with cerebral fluid fistula. Each patient had preoperative nasal endoscopy and CT/MRI imaging performed. Then they underwent endoscopic transnasal sphenoidotomy with removal of the lesion or closure of the fistula. The sphenoid sinus was approached through its front wall. Results: The patients’ postoperative course was uneventful. They noted improvement in all preoperative symptoms, Conclusions: Isolated lesions of the sphenoid sinus, can be in most cases safely approached and removed endoscopically. All risks of the method must be considered prior to the operation. High frequency of fungal sinusitis should be noted.

A378 Bony changes in hypertrophic rhinosinusitis: comparitive study between virgin cases and recurrence L. Telmesani*, A. Lotfy, K. Abushamah King Fahad University Hospital, Riyadh, Saudi Arabia The main problem in management of nasal polypi is the recurrence of the disease. It was observed that revision patients are more vulnerable for further recurrences. Study design: Prospective study to evaluate the incidence of osteitis in virgin and recurrent cases of nasal polypi and to relate that to recurrence of the diseases. 82 patients with bilateral nasal polyposis divided into 2 groups; (A) 50 patients had no previous surgery and (B) 32 patients undergoing revision surgery. Histopathological examination was performed for bony septa of the ethmoid including mucosa and underlying bone. Results: Bony changes were seen only in 30% of patients in group A and 87.5% in group B, this was statistically significant. Recurrence was seen in 10% (5 patients) of patients of group A, and 53% in group B, this represent 60.7% of patients with osteitis. This was found highly significant. The incidence of recurrence related to the degree of osteitis as 25% of patients with mild osteitis showed recurrence, 66.6% of patients with moderate osteitis showed recurrence and 100% of patients with severe osteitis showed recurrence of the nasal polypi. Conclusions: Osteitis is an important factor for recurrence of nasal polypi, surgery increases the incidence of osteitis. medical treatment for nasal polypi should be tried first and surgery is done only in cases of failure of medical treatment.FESS with complete removal of bony partition within the diseased area can control a persistent source of inflammation.

A379 Can we reduce morbidity in invasive fungal infections? G. Mankekar* PD Hinduja National Hospital, Mumbai, India Invasive fungal infections are associated with high incidence of morbidity and mortality. Early suspicion of the condition, rapid microbiological diagnosis, aggressive debridement with systemic antifungal therapy and supportive management enable successful management of the condition. This paper discusses the possibility of minimising morbidity to enable patients to have a good quality of life.

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A380 Changes of paranasal sinus mucosa: experimental study on rabbits F. Manole* University of Oradea, Oradea, Romania The purpose of the study is to determine the effects of the artically induced mechanical obstruction on the physiopathology of the paranasal sinus mucosa, taking into consideration an experimental model on animals, with the alteration of the nasal air-flow. The study was performed on 20 New Zealand white rabbits, distributed into two equal groups. In the case of the first group of 10 experimental animals, we induced the model of ipsilateral double obstruction, the opposite side being left intact as term of comparison. Thus we produced the mechanical obstruction of the nasopharynx at the level of the choanal orifices, as well as, the obstruction at the level of ostiomeatal complex. In the case of the second experimental group we induced the model of the double contralateral obstruction: the obstruction of the nasopharynx at the level of the choanal orifices and the contralateral obstruction of the ostiomeatal complex. The procedures were performed surgically under surgical microscope. We studied and determined the microscopically anatomopatological changes of the paranasal sinus mucosa. The study determines the anatomopathological aspects of normal unobstructed sinus mucosa and the presence of inflammatory infiltrations, which are more accented tending to be chronical in the case of obstruction of the maxillary sinus at a level of ostiomeatal complex and nasopharynx (double ipsilateral obstruction). The anatomopathological aspects of sinusal mucosa in experimental animals are linked to the changes due to the locally induced sinus obstruction.

A381 Characterization of paranasal devices in a human nasal cast: do in-vitro data support promises? U. Schuschnig*, A. Kru¨ner, M. Keller PARI Pharma GmbH, Mu¨nchen, Germany Introduction: Companies selling sinonasal nebulizers claim to deliver medications to the sinuses, but these claims are not supported by valid in-vitro or in-vivo studies. Objectives: This study was carried out to compare nebulizers including a novel prototype device (VibrENT) generating a fine aerosol mist via a pulsation aerosol principle utilizing a nasal cast model. Methods: Four commercially available sinonasal nebulizers and a VibrENT prototype were tested according to their instructions of use. Nebulization efficiency was measured using a nasal cast model (Moeller, 2008, Rhinology) linked to a breath simulator mimicking nasal breathing. The nebulizers were filled with a novel Levofloxacin formulation and nebulized for 8 min each. At the end of nebulization, the nasal cast was disassembled and drug from the paranasal cavities including ostia, the nasal cavity, as well as the inspiratory filter was assayed by HPLC. Results: The VibrENT prototype delivered 1.0% of the loaded dose to the paranasal cavities and this deposition fraction increased to 19% mimicking a closed soft palate. All other devices tested delivered less than 0.06% of the charged drug to the paranasal cavities. Nasal cavity deposition was 3% for the SinuNeb, 12% for the Aeroneb Go and 50% for the VibrENT. In-vitro lung deposition was

1141 2% for the Atomisor AMSA, 8% for the VibrENT and 12% for the Aeroneb Go. Conclusions: Current sinunasal drug delivery systems do not provide adequate paranasal drug deposition using a human nasal cast. The VibrENT prototype showed promising in-vitro results but clinical studies are needed to validate in-vitro results.

A382 Choanal atresia: 20 years experience V. Subarevic1*, K. Stankovic1, I. Baljosevic1, L. Cvorovic2, L. Pavicevic3 1 Pediatric ENT Department, Mother and Child Health Care Institute of Serbia ‘‘Dr Vukan Cupic’’, Belgrade, Serbia; 2ENT Department, University Hospital ‘‘Zemun’’, Belgrade, Serbia; 3ENT Department, Military Academy, Belgrade, Serbia Choanal atresia is congenital malformation of the head and it represents unilateral or bilateral undeveloped posterior opening of the nasal cavity. It occurs in 1 of 8,000 newborn babies. We think that choanal atresia frequency is bigger, because it is one of the unknown cause of neonatal deaths. Approximately 60–70% of choanal atresia are combined with other congenital malformations and syndromes. Unilateral choanal atresia (UCA) usually is clinically manifesting later than bilateral (BCA). Opposite unilateral, bilateral choanal atresia is emergency situation which is manifesting immediately after birth and it needs immediate intervention. The aim of our study was to show the results of choanal atresia treatment in children within 20 years long period in Pediatric ENT Department at Mother and Child health care Institute of Serbia ‘‘Dr Vukan E`upiæ’’ in Belgrade. Every possible suspicion at choanal atresia demands multidisciplinary approaching which means main symptoms recognizing on time by neonatology doctors, giving the first aid by intensive care doctors or anesthesiologist (orofaringeal tubes, nasogastric tube for eating or intubations), making choanal atresia diagnosis, definitive treatment and regular postoperative following up by pediatric ENT doctor.

A383 Chronic invasive fungal rhinosinusitis in the immunocompetent patient: report of three cases C. Makrypides, E. Gletsou, E. Theos, C. Evaggelopoulos, C. Gantas, P. Pavlides, V. Lachanas*, T. Apostolidis Otorhinolaryngology, Head and Neck Surgery Department, School of Medicine, University of Thessaly, Larissa, Greece Introduction: Aspergillus sinusitis in cases without evidence of immunodeficiency is very rare. We report three cases of apparently immunocompetent patients with sinus aspergillosis. Cases series: A 45-year-old female presented with headache persistent for at least 1 year. CT-scan showed right maxillary, ethmoid and sphenoid infiltration. FESS was performed and histology showed aspergillosis. Without adjuvant antimycotic therapy the patient is stable for more than 2 years. A 25-year-old female, who had twice

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1142 undergone paranasal sinus surgery with external procedure for chronic sinusitis, presented with periorbital pain and right proptosis. CT-scan revealed infiltration of the right orbit. Endoscopic biopsy revealed aspergillus hyphae. No vision loss or pathological visual fields were identified. Systemic therapy with amphotericin B for 1 month followed by itraconazole and ambisome for 1 year performed, resulting in clinical improvement. The patient is clinically stable for a 2 years follow up period. A 74-year-old man with sinusitis referred with nasal discharge, blocking, recurrent epistaxis and decreased sense of smell. CT and MRI revealed infiltration of the maxillary bony wall and erosion of the inferior turbinate. The whole lesion was totally removed endoscopicaly. Microbiological and histological examination of large bony specimens showed aspergillus hyphae. Postoperatively ketoconasol was administrated for 2 months. The patient is clinically stable at follow up. Conclusion: Multiple pre-operations of the paranasal sinuses combined with persistent headache should raise suspicion of aspergillus rhinosinusitis, even in immunocompetent patients. Early diagnosis and treatment is essential in preventing life-threatening complications or irreversible visual loss.

A384 Chronic rhinitis in children: does it change following adenoidectomy? M. Warman1,2*, Y. Poria1,2, E. Granot2, D. Halperin1,2 Withdrawn

A385 Clinical features of the odontogenic sinusitis : report of 27 cases K. Lee*, S. Lee, N. Lee Department of Otorhinolaryngology-Head and Neck Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea Objectives: This study aimed to determine the clinical features, etiologic factors and radiologic findings of odontogenic sinusitis and report on the most appropriate diagnostic and therapeutic patterns for earlier diagnosis and successful treatment of the disease. Study design: Retrospective chart review. Subjects and methods: Twenty-seven patients (30 cases) with various odontogenic sinusitis, who were treated at Kangbuk Samsung Hospital between 2006 and 2008, were analysed. In this group, There were 15 males and 12 females with mean age at presentation of 42.9 years. A retrospective chart review was performed with respect to the clinical features, etiology, CT scan of paranasal sinuses. Results: Several conditions cause odontogenic sinusitis. Ten patients (37.0%) had implant related complications, 8(29.6%) dental extraction related complications, 3 (11.1%) dentigenous cyst, 2 (7.4%) radicular cyst, 2 (7.4%) dental caries related complications, and 2 (7.4%) had supernumenary tooth. Purulent nasal discharge was the most common symptom(66.7%), followed by cheek pain (33.3%), offensive odor (25.9%) and nasal obstruction (18.5%). Evidence of definitive diagnosis by history taking and CT scan of paranasal sinus was obstained in almost all cases.

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Conclusions: In our study, most common cause of odontogenic sinusitis was implant related complications (37.0%). By reporting this study, we must to call attention to the relationship between odontogenic source and maxillary sinusitis and take into consideration of implant related complications in suspicious cases of maxillary sinusitis.

A386 Clinical significance of the sphenoidal process of cartilaginous nasal septum S. Kim*, J. Kim, S. Kim, J. Cho, Y. Park Department Otolaryngology-Head and Neck Surgery, The Catholic University of Korea, Seoul, Korea The nasal septum is completely cartilaginous skeleton in embryonic life and ossifies to form perpendicular plate of ethmoid (PPE) and vomer. A small strip of cartilage from cartilaginous septum remains between PPE and vomer, so-called sphenoidal process of cartilaginous septum. The purpose of this study was to evaluate the clinical significance of sphenoidal process of cartilaginous nasal septum. The study population consisted of 51 patients with septal deviation to one side undergone septoplasty. The complex of sphenoidal process, PPE and vomer was obtained during septal surgery. Measurement of the length of sphenoidal process and histological evaluation were made and compared with normal control group. We also compared with the length of sphenoidal process to the deviated angle of nasal septum on computed tomography of the sinuses. The mean length of sphenoidal process in patients with deviated nasal septum was 26.86 ± 6.28 and that of normal control was 11.95 ± 2.38. The length of sphenoidal process increased significantly in patients with deviated nasal septum compared to normal control (P \ 0.05) and correlated with the deviated angle of nasal septum in the nasal valve and anterior ostiomeatal unit. The sphenoidal processe of cartilaginous septum connected with PPE and vomer in patients with deviated nasal septum had different histological findings from normal person. This study suggests that a course of ossification in the cartilaginous nasal septum would be one of the leading causes of nasal septal deviation.

A387 Comorbidities and complication of allergic rhinitis M. Kirjas1*, K. Obocki2* 1 ENT Department, Clinical and University Center, Skopje, Macedonia; 2Pulmonology Department, Skopje, Fyro Macedonia Alergic diseases have been described as a modern epidemic. The comorbidity of allergic rhinitis with asthma—the ‘‘oner airway’’ hypothesis is generally accepted, but other relevant comorbidities involving the eyes, throat, ears and voice are still being elucidated. Accurate diagnosis and effective treatment can reduce other chest and problems. Rhinitis, both allergic and non-alergic, is associated with effects on surrounding structures: eyes, sinuses, ears and lower airways. Rhinitis may appear first and be causative. Adequate treatment of rhinitis can have ameliorating effects.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Individuals with otitis media with effusion, pharyngitis,laryngitis, sleep problems and asthma or chronic cough need through investigation for concomitant rhinitis plus adequate treatment if present.

A388 Comparison of clinical manifestations between primary and secondary paranasal mucoceles K. Lee*, N. Lee, S. Lee Department of Otolaryngology-Head and Neck Surgery, Kangbuk Samsung Hospital, Sungkynkwan University School of Medicine, Seoul, Korea Background and objectives: The purpose of this study was to describe the clinical characteristics of primary mucocele that had no previous sinus surgery history nor known cause of mucocele, and secondary mucocele as a result of the complications after endoscopic sinus surgery or Caldwell-Luc operation, and to compare them. Materials and methods: We performed retrospective chart review of 33 cases of primary mucocele and 60 cases of secondary mucocele which were diagnosed and underwent operation at Kangbuk Samsung Hospital between 1996 and 2008. Results: The most common presented symptoms were nasal obstruction (19.4%), rhinorrhea (17.7%) in primary mucocele. In secondary mucocele, cheek pain (31.7%) and nasal obstruction (18.3%) were most common symptoms. The origin of primary mucocele is ethmoid (45.5%), maxillary sinus (18.2%). In secondary mucocele, maxillary sinus was most common site (86%), followed by ethmoid sinus (7.1%). All of secondary mucocele had previous sinus surgery before mean 18 years ago. Conclusions: Several literatures reveal that most of sinus mucocele in Asian occur in maxillary sinus in relation to long term complication of Caldwell-Luc opeartion. In our study, in the secondary mucocele, maxillary sinus was the most common site. However, most common site of the primary mucocele is ethmoid sinus. Also the secondary mucocele that underwent previous sinus endoscopic surgery, not Caldwell-Luc operation, developed more frequently in ethmoid sinus. We conjecture that the incidence of maxillary sinus mucocele in Asian will be decreasing as endoscopic sinus surgery increases.

A389 Comparison of Packs for anterior epistaxis N. Doddi* Prince Charles Hospital, Brisbane, Australia Objectives: 1)

Pain caused by anterior nasal packs during insertion, in situ and removal. 2) Ability of the packs to stop epistaxis; 3) Difficulty of use for the clinician. Design: Prospectively evaluating patients admitted with nasal packs for anterior epistaxis using a questionnaire reflecting the objectives of the study. Setting: Two District General Hospitals- Prince Charles Hospital, Merthyr Tydfill and Fairfield Hospital, Bury.

1143 Participants: 45 patients with anterior epistaxis refractory to digital pressure and cautery between February and October 2008. Main outcome measures: Subjective perception of pain was measured on a visual analogue scale of 0–10, 0 being the least painful. Haemostatic ability of the pack was graded on a scale of 0–3 where 0 is significant bleeding needing further intervention. Difficulty of use was graded on a scale of 0–10 where10 is the most difficult. Results: The mean pain scores during insertion, insitu and removal for Rapid Rhino were 4.71, 3.14 and 3.0 respectively, BIPP were 7.14, 3.6 and 4.0 respectively and Merocel were 6.13, 3.5 and 4.0 respectively. Haemostatic ability of BIPP and Rapid Rhino was 2.80 while it was 2.50 for Merocel. The mean score of difficulty of use for Rapid Rhino was 3, Merocel was 2 and BIPP was 8. Conclusions: Rapid Rhino when compared to Merocel and BIPP is significantly more comfortable for the patient, easier to use for the clinician and is equally effective in controlling the bleed.

A390 Contemporary indications for endoscopic nose and paranasal cavity surgery in children V. Stojanovic Kamberovic1*, G. Bjelogrlic2*, M. Bozovic3*, S. Babac4*, G. Videnovic5*, R. Kosanovic4* 1 Zvezdara Health Center Belgrade, Belgrade, Serbia; 2 Institute of ENT and MF Surgery, Clinical Centre of Serbia, Belgrade, Serbia; 3Medical Center Uzˇice, Belgrade, Serbia; 4Department of Oto-Rino-Laringology, ‘‘Zvezdara’’ Hospital and Clinical Centre, Belgrade, Serbia; 5School of Medicine Prisˇtina, Clinical for MFSKosovska Mitrovica, Kosovska Mitrovica, Kosova Introduction: Well defined criteria and indications for functional endoscopic sinus surgery (FESS), recognizing the potential complications and possible consequences, are essential for the correct treatment of pathological processes of this extremely subtle area of juvenile pathology. Objective: The importance of correctly defining the indications for surgical nose treatment and PNS by endo-nasal method at the age of childhood. Method: A prospective 5-year study was carried out on 28 patients, who were treated for FESS (Karl Storz-Hopkins II Telescopes) of the nose/PNS. The subjects were of 10.80 ± 4.16 mean age, i.e. 4–16s years of age. Indications for operational treatment were based on: anamnesis, clinical ENT examination, radiographic procedures, bacteriological/micological analyses of nose/PNS aspirates, alergological, ophtalmological/neuro-ophtalmological procedures. Results: Out of 28 patients, 60.71% aged between 12 and 16, and 82.14% were of masculine sex. Chronic sinusitis with/without nasalsinus polyposes was diagnosed in 46.42%. Complete nasal obstruction in cases of cystic fibrosis, antrochoanal polyp, juvenile angiofybroms and orbital suppuration were diagnosed in 4 patients, while traumatized injury of the optical channel in 2 patients. Fungal sinusitis, intracranial complications of sinusitis and mucocele/mucopiocele were noted in 32.14%. Surgical treatment was preceded by therapy with medicaments, and was often continued after the intervention (antibiotics/antihistamines/corticosteroids/ASIT). Conclusion: The specificity of organisms in children, their growth and change call for a conservative and cautious approach in endonasal surgical therapy. FESS was a method of choice for treatment of

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1144 benign lesion, orbital sinusogenic complications, acute/chronic rhinosinusitis, especially in nasal-sinus-polyposis. The successful outcome scored 89.28%. Keywords: FESS, Indications, Children.

A391 Correction of septal nasal perforation (NSP) with graft and mucosal flap procedure S. Amiry Andi1*, M. Vahidy2 1 Department of Otolaryngology-HNS, Imam Khomaini Hospital-Ilam, Ilam, Iran; 2Department of OtolaryngologyHNS, Imam Sadegh Hospital-Yazd, Yazd, Iran Objective: NSP often lead to crusting inside nose,epistaxis and sometimes whistle and obstruction of nose. Recurrency most occur in large septal perforation but this approach is successful. Materials and methods: If medical treatment could not control the symptoms, surgical procedure advised. In our method we used advanced mucosal flap two sides with putting temporal fascia graft in the region of septal perforation via an open rhinoplasty approach. Result: In ten patients that the surgical procedure was done the size of septal perforation was greater than 2 cm2 and the success result was 80% in which can be compare with other procedures. In two patients with recurrent 1st the size of defect become smaller, 2nd the patient was without symptoms. Conclusion: With attention to result in this study, correction of NSP in with the size is greater than 2 cm2 with flap and temporalis fascia graft is successful. Keywords: Nasal septum, Septal perforation, Advancement flap

A392 CT score at the patients with uncomplicated and complicated form of chronic rhinosinusitis Z. Dudvarski1*, V. Djukic1, L. Janosevic1, S. Jesic1, N. Arsovic1, M. Dimitrijevic1, P. Vasiljevic2 1 Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre of Serbia, Belgrade, Serbia; 2ENT Department, City Hospital, Belgrade, Serbia In order to assess the extent and severity of inflammatory changes in paranasal sinuses CT score according to Lund-Mackay is the most commonly used. The aim of this study was to examine the influence of sinonasal polyposis on the Lund-Mackay CT score at the patients with chronic rhinosinusitis. Materials and methods: Prospective study compared the LundMackay CT score values within the group of patients with and without nasal polyps. We determined mean values of the total CT score in both group of patients as well as mean values of CT score for the each group of sinuses and ostio-meatal complexes. Results: The study comprised 90 consecutive adult patients, 47 male and 43 female, 45 years old on average, who were diagnosed with chronic rhinosinusitis on the basis of diagnostic algorithm. Within group with uncomplicated chronic rhinosinusitis (without nasal polyp) we had 30 patients and in the group with complicated

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 chronic rhinosinusitis (with nasal polyp) 60 patients. Observing these two groups of patients statistical highly important intergroup difference in CT scor was found for each group of sinuses and ostio-meatal complexes. Mean value of total CT score in the group with uncomplicated chronic rhinosinusitis is 4.37 while in the group with complicated chronic rhinosinusitis is 16.05 (P \ 0.01). Conclusion: Chronic rhinosinusitis complicated by sinonasal polyposis is characterized with more extensive inflammatory changes on CT and consequently higher CT score for each group of sinuses and ostio-meatal complexes as well as higher total CT score.

A393 Diode laser trans-canalicular endoscopic dacryocystorhinostomy and intraoperative application of C-Mitomicine C under local anesthesia P. Santos Acosta1, R. Corrales Milla´n, J. Gonza´lez Garcı´a, S. Sa´nchez Go´mez 1 Seville, Spain Introduction: Dacryocystorhinostomy (DCR) is the treatment of choice for nasolacrimal duct primary acquired obstruction. We report our results with diode laser trans-canalicular endoscopic dacryocystorhinostomy and intraoperative application of C-Mitomicine C. Materials and methods: We carried out a prospective descriptive study between January 2007 and January 2008 of 187 diode laser trans-canalicular endoscopic dacryocystorhinostomy under locoregional nasal anesthesia and topical ocular anesthesia. C-Mitomicine was placed in all cases intraoperatively and at 15 days after the surgery. Main outcome measure was resolution or improvement of epiphora. Patients were followed at least 9 months. Results: Variables like sex, age, sick eye, time of evolution of the pathology, type of anesthesia and complications are described. Our results demonstrate the effectiveness of endoscopic trans-canalicular approach with laser diode and local anesthesia. Success rate at 9 months postoperatively was 95.8% (179, 15). Epiphora disappeared in 60.3% (112, 76), of patients and improved in 35.5%(66, 38), 4.1%(7, 67) did not improve after the surgery. Discussion/conclusion: Endoscopic transcanalicular DCR with diode laser is a fast and safe technique it produces minimum tissue harmfulness and minimum morbidity for the patient. Success rate is similar to other external and endoscopic techniques. Ambulatory regimen is possible by using local anesthesia and extends the indications to general anesthesic high risk patients. Our preliminary results show a low incidence of recurrence with C-Mitomicine application compared with non-using references. A larger population and following time is needed to a establish definitive conclusions.

A394 Diode laser-assisted endoscopic DCR without stenting: our experience C. Sarafoleanu*, C. Manea ENT Department ‘‘Sfanta Maria’’ Hospital, Bucharest, Romania Endoscopic DCR is nowadays the procedure of choice in postsaccal stenosis of the nasolacrimal duct, due to various factors

Eur Arch Otorhinolaryngol (2009) 266:1039–1158

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including infections or trauma. A controversial issue regarding the technique is that of using the stenting at the end of the surgical procedure. According to the literature the long term results seem to be the same. The paper present our group of 31 patients with endoscopic DCR that were operated on without stenting during the last 3 years. All the patients received the same diagnostic and therapeutic protocol. We perform a wide opening in the medial wall of the lacrimal sac and, at the end of the surgical procedure, diode LASER was applied at the margins of the saccal defect in order to avoid the stenosis. Usually the opening is 3–4 times bigger than the estimated diameter of the stent. We present the surgical technique and the group of patients that included 4 posttraumatic cases, 5 children with malformative syndromes and 22 adults with chronic infections. We obtained a good permeability of the opening in 87% of our cases. Four patients (13%) required reevaluation of the medial sac wall area and reintervention using different methods. In conclusion we can say that the marsupialisation (non stenting) method for DCR is of real value. The success rate is quite similar with other methods, the surgeon’s experience and preference is essential for the surgical technique decision.

Patients and methods: Prospectively data collection for 100 consecutive patients admitted to the department of Otolaryngology with epistaxis over 1 year (August 2006–2007). The demographics, co-morbidities, long term medications and the blood test results were noted for these patients. Retrospective audit of all patients attending the Accident and Emergency department with a presenting complaint of epistaxis during the same study period was then carried out. Results: Of the 100 admitted patients, 45 were male and 55 were female. Majority of them had more than two systemic diseases like hypertension, ischaemic heart disease and atrial fibrillation. Fortyseven patients were on aspirin, 19 were on warfarin and 12 patients were using clopidogrel. Clotting screen was done for 80 patients but only two patients (2.5%) had an abnormal INR. A total of 356 patients attended accident and emergency department. of 356 patients, 138 (39%) had their clotting screen checked. of 138 patients, 42 (30%) were on warfarin. Only 7 patients (7/138 = 5%) had an abnormal result. Discussion: Our study shows that routine clotting screen check in patients with no risk factors or even with stable warfarin dosage does not alter their management. Therefore, routine clotting screen check in patients with epistaxis without any risk factors is not a good practice.

A396 Diplopia as a complication after nasal septoplasty and radiofrequency ablation of inferior turbinate: a case report

A398 Effective treatment of chronic rhinosinusitis with fluticasone propionate administered using the OptiNose delivery device

Z. Ansari1*, S. Atighechi, M. Jabbari 1 Janbaz Sq. Shahid Sadoughi Hostpital ,Otolaryngology Dep., Yazd, Iran

F. Hansen2*, T. Flint3, G. Hewson3, P. Djupesland1, W. Fokkens2 1 OptiNose AS, Oslo, Norway; 2Academisch Medisch Centrum, Amsterdam, The Netherlands, 3OptiNose UK Ltd, Wiltshire, UK

A 19-year-old boy had temporary diplopia due to limited motion of the medial rectus muscle of his right eye after bilateral radiofrequency ablation of the inferior turbinate and septoplasty. Post operative imaging (CT scan and MRI of the orbit and brain) did not disclose any intraorbital or cranial abnormalities except edema of the right orbit, inflammation in right anterior ethmoid cells, and in T2 MRI there was a little edema in the medial rectus muscle. The patient was treated with oral prednisolone 1 mg/kg/day on a tapering schedule. Within three months, the ophthalmic abnormalities completely resolved. This is a very rare report to describe such ophthalmic complication, which is attributed to temporary paresis of the medial rectus muscle due to its inflammation, secondary to septoplasty and radiofrequency ablation of inferior turbinate. Keywords: Diplopia, Septoplasty, Radiofrequency, Complication

A397 Does routine clotting screen impact epistaxis management in adults? M. Shakeel*, T. Iddamalgoda, A. Trinidade, K. Ah-See Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK Introduction: Routine clotting screen in patients presenting with epistaxis is not recommended. Despite this fact, this test is routinely requested by the attending physicians. Aim: To investigate the role of clotting screen in adult patients presenting with epistaxis.

Introduction: Chronic rhinosinusitis (CRS) severely impacts on quality of life, with few effective treatments currently available. OptiNose’s breath-actuated, bi-directional nasal delivery device improves middle meatus deposition, considered essential to achieve clinical effects in CRS with a topical steroid. Methods: Efficacy and safety of fluticasone propionate selfadministered using OptiNose’s delivery device (Opt-FP) were assessed in a prospective, single centre, randomized, double-blind, parallel group, placebo-controlled pilot study in 20 adult patients with CRS without nasal polyps or with only cobblestone polyps grade 1 (Lildholdt’s scale). Opt-FP 400 lg or placebo (PBO) was delivered twice daily for 12 weeks (n = 10 subjects/group). Subjects were permitted to use saline rinse. Loratidine tablets were provided as rescue medication. Results: Endoscopy score for oedema showed a progressive improvement (Opt-FP -3.1, PBO -1.0, P \ 0.01). PNIF was increased (4 weeks: P \ 0.01; 8 weeks: P \ 0.05). Non-significant increases in nasal volumes measured by acoustic rhinometry were observed. Total RSOM-31 QOL-score and all subscale scores also improved against placebo. The nasal RSOM-31 subscale was improved (4 weeks: P \ 0.05, 8 weeks: P \ 0.01, 12 weeks: P = 0.053). Overall VASscore showed an improvement trend (Opt-FP -23.6, PBO -3.3, P = 0.19). Diary scores for sense of smell, nasal discomfort and combined score, both morning and evening, were all significantly improved (P \ 0.05). A non-significant reduction in mean percentage days of loratidine usage was observed for Opt-FP. Conclusions: Fluticasone propionate (400 lg b.i.d) administered using OptiNose’s breath-actuated bi-directional delivery device was highly effective in treating CRS with significant improvements over placebo. The treatment was safe and well tolerated.

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A399 Effective treatment of nasal polyps with fluticasone propionate administered using the OptiNose delivery device P. Djupesland1*, T. Flint2, C. Sheldrake2, G. Hewson2, I. Vlckova3 1 OptiNose AS, Oslo, Norway; 2OptiNose UK Ltd, Wiltshire, UK; 3Department of OtRL, Palacky University, Olomouc, Czech Republic Introduction: Existing nasal delivery methods are suboptimal in reaching important target sites beyond the nasal valve. OptiNose’s novel breath actuated bi-directional nasal delivery device significantly improves deposition to regions essential to achieve clinical effects in polyposis. Methods: Efficacy and safety of fluticasone propionate (400 lg b.i.d.) using OptiNose’s delivery device (Opt-FP) were assessed over 12 weeks in a prospective, multicentre, randomized, double-blind, parallel group, placebo (PBO)-controlled study in 109 adult patients with bilateral polyps grade 1 or 2 (Lildholdt’s Scale). Results: The proportion of subjects with an improvement in summed polyp score C 1 on the Lildholdt’s Scale was significantly higher compared to placebo at 4, 8 and 12 weeks (22.2% vs 7.3%, P = 0.011, 42.6% vs. 7.2%, P \ 0.001, 57.4% vs. 9.1%, P \ 0.001). PNIF increased progressively at 4, 8 and 12 weeks (Week 12 Opt-FP 17.7 L/min; PBO -3.2 L/min, P \ 0.001). Overall improvement in combined symptom score was reported at all time points (P \ 0.001). Nasal blockage, nasal discomfort, rhinitis symptoms and sense of smell were all significantly improved. Rescue medication use was lower in the Opt-FP group (3.1% vs. 22.4%, P \ 0.001). Epistaxis was observed only in the active group (11.1%). Morning plasma cortisol levels were unchanged after 12 weeks. Conclusions: Fluticasone propionate (400 lg b.i.d.) administered using OptiNose’s breath actuated bi-directional nasal delivery device was highly effective in treating mild to moderate nasal polyps. All parameters assessed were significantly and progressively improved compared to placebo. The treatment was safe and very well tolerated.

A400 Endoscopic transseptal approach to frontal sinus disease S. Nishiike1*, S. Yoda2, J. Murata1 1 Department of Otolaryngology and Sensory Organ Surgery, Osaka University Graduate School of Medicine, Osaka, Japan; 2Department of Otolaryngology, Kawasaki Medical School, Okayama, Japan Endoscopic sinus surgery for the frontal sinus remains problematic, because of the complex anatomy and large anatomical variation of the frontal recess. An endoscopic transseptal approach is simple to identify and access the frontal sinus. At the first step of this procedure, we open a 5 9 5 mm window in the bilateral anterior portion of the middle turbinates and nasal septum. The drill is raised up just behind

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 the nasal bone along a guideline for the midline of the nose indicated by the remaining part of the nasal septum. After the bilateral frontal sinuses and their posterior walls are confirmed, the interfrontal septum is removed superiorly. We have managed twelve patients in this fashion. Neither intracranial nor orbital complications were encountered during or after surgery. Endoscopic transseptal frontal sinus surgery is simple to perform, and does not cause severe complications.

A401 Expression and distribution of the intermediate filament protein nestin in the human olfactory epithelium A. Minovi1*, H. Benecke2, H. Hatt2, S. Dazert1 1 Department of Otorhinolaryngology, Head- and Neck Surgery, St. Elisabeth Hospital, Ruhr-University Bochum, Bochum, Germany; 2Department of Cell Physiology, Ruhr-University Bochum, Bochum, Germany The olfactory epithelium (OE) is unique in regenerating throughout life and thus became an attractive target to examine neurogenesis. The nestin protein was shown to be expressed in the OE of rodents and is suggested to be essentially involved in the process of regeneration. Here we report the expression and distribution of nestin in the human OE. Moreover, we compare expression profiles on protein and mRNA level in dependence on the age and on the olfactory capacity using immunohistochemistry and RT-PCR analysis. After sinus surgery, biopsies were taken from the olfactory epithelium of 18 patients aged 20–80 years with documented differences in their olfactory function. Our studies revealed that nestin is constantly detectable in the apical protuberances of sustentacular cells within the human OE of healthy adults. Its expression is not dependent on the age but rather appears to be related to the olfactory function, as a comparison with specimens obtained from patients suffering either from persistent anosmia or hyposmia suggests. Particularly, in the course of dystrophy often accompanying the OE of patients with impaired olfaction, nestin expression was occasionally decreased. Contrarily, the expression of the p75-NGFR protein, a marker for human OE basal cells, was not altered, indicating that at least in the tested samples olfactory impairement is not connected with abnormalities on the basal cell level. These observations supplementary emphasize an essential role of nestin for the process of regeneration and moreover highlight this factor as a candidate marker for sustentacular cells in the human olfactory epithelium.

A402 Facial pain in chronic rhinosinusitis: correlation with nasal endoscopy and CT A. Agius* University of Malta Medical School, Guardamangia, Malta Commonly attributed to chronic sinusitis, facial pain is a frequent presenting complaint in otolaryngology clinics. This study aimed to

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 correlate facial pain with nasal endoscopy and CT in such patients. The setting was a busy otolaryngological practice on a small Mediterranean island. A cohort of 305 consecutive patients with chronic rhinosinusitis refractory to maximal medical therapy was assessed clinically, by nasal endoscopy and coronal sinus CT. The primary presenting symptom in 154 of these individuals was facial pain. Using the Lund-McKay scoring system, a CT positive for sinusitis was set at 2 or higher. A score of 0 or 1 was considered negative for sinusitis. The CT in 61 (40%) patients with facial pain scored positive while 93 (60%) patients had a negative CT. Patients with facial pain as the presenting symptom in rhinosinusitis were significantly less likely to score positive for sinusitis on CT (chi squared test, P \ 0.0001). CT positive patients were significantly more likely to have pus or nasal polyps (chi squared test, P \ 0.0001) on nasal endoscopy than CT negative patients. Only 36% of patients with facial pain and other sinusitis symptoms had chronic rhinosinusitis as confirmed by CT and presence of pus or polyps on nasal endoscopy. Patients with positive CT were significantly more likely to be treated surgically while those with a negative CT were significantly more likely to be treated by medication (chi squared test, P \ 0.0001). Patients were followed up for a mean of 2 years and their outcomes analysed.

A403 Fluticasone propionate aqueous nasal spray does not influence the recurrence rate of chronic rhinosinusitis and nasal polyps 1 year after functional endoscopic sinus surgery D. Marev Departement of Otorhnolaryngology Universiti Hospital ‘‘Sv.Marina’’-Varna, Varna, Bulgaria Background: Local corticosteroids are widely used in the treatment of nasal polyps and chronic rhinosinusitis both before and after nasal surgery. Their efficacy after functional endoscopic sinus surgery (FESS) has not been fully established by placebo-controlled trials. Objective: This double-blind placebo-controlled randomized study was performed in order to investigate whether fluticasone propionate aqueous nasal spray (FPANS) reduces the recurrence rate of nasal polyps and chronic rhinosinusitis during the first year after FESS. Methods: The trial looked at 162 patients aged 18 years and older requiring FESS for chronic rhinosinusitis or nasal polyps. Patients were withdrawn from the trial if there were recurrent or persistent diseases, defined as progressive regrowth of nasal polyps, recurrent signs and symptoms of chronic sinusitis combined with abnormalities on computed tomography scan and persistent complaints for at least 2 months after FESS. Results: A significant reduction of symptoms was seen after FESS. After 1 year, 46 patients had been withdrawn from the trial because of recurrent diseases and 32 patients because of persistent symptoms. No differences in the number of patients withdrawn because of recurrent or persistent diseases were found between the patients treated with FPANS and patients treated with placebo. We were also unable to find a positive effect of FPANS compared with placebo in several subgroups such as patients with nasal polyps, high score at FESS or no previous sinus surgery. Conclusion: This placebo-controlled study does not show that treatment with FPANS up to 1 year after FESS had a positive effect compared with placebo.

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A404 Fronto orbital and ethmoid mucoceles management N. Perez*, P. Martinez-Seijas, U. Bolinaga*, R. Lobato*, J. Arruti, J. Rad Hospital Donostia San Sebastian, Spain Mucoceles are retention pseudotumours in the paranasal sinuses due to the obstruction of the drainage ostium in the oseomeatal functional unit of the middle meatus. The frontal sinus and the anterior ethmoidal sinus are the most frequently affected forming mucoceles. Clinical case: 65 years old male patient present a right a painless palpebral swelling tumefaction without phloghosis, present for 8 months. The patient did not refer trauma or sinuses surgery. Diagnostic techniques: FNAC: a yellowish thick liquid was obtained. CT scan: multilocular cystic tumour with expansio´n of the frontal sinus and reabsortion of the right orbital roof, the posterior wall of the frontal sinus and the anterior ethmoidal cells. MRI: Multilocular cystic tumour hypointense in T1 an hyperintense in T2. Surgical treatment: Coronal approach and dissection of the supratrocheal and supraorbitary nerves. The access to the mucoceles by frontal bone osteoplasty. Blunt dissection of the multilocular cystic tumour from the surrounding tissue and the sphenoid region. Ostheosynthesis with reabsorbable miniplates and closure of Incision. Discussion: Diagnosis is made by means of MRI, CT scan, FNA for microbiological or pathological study. Conclusions: • •

•

Frontoethmoid mucocele is the most frequent. They clinically present as pseudotumours and/or migraines. If they affect the orbit: diplopia, proptosis and in some cases decrease in visual acuity. The treatment of choice is the surgical endoscopic technique modified by Lothrop except in sinus with septum or lateral extensions.

A405 Fronto-ethmoidal mucocele navigator system-assisted endoscopic surgery: case report M. Cisternas Bittencourt*, E. De la O Corrochano, G. Fernandez Rodriguez, M. Castro Canelada, M. Marti Pen˜a, C. Salazar Cabrera, M. Aparicio Perez Department of Otorhinolaryngology, Head and Neck Surgery, Hospital San Pedro de Alcantara, Ca´ceres, Spain Objectives: Mucocele is a histopathologically benign, cystic expansion of paranasal sinuses filled with mucoid content. Most of the mucoceles develop in the frontal sinus, less frequently they may arise in the ethmoid, maxillary or sphenoid sinuses. The pressure of the contents of the mucocele induces remodelation and destruction of the sinuses’ walls giving rise to the external signs and symptoms related to structure displacement. In recent years, endoscopic sinus surgery has gained more attention in the surgical treatment of mucoceles. Methods: A case of a 78 year old woman with a tumor in the medial left eye cantus is discussed. Results: The patient had a long term tumor in the medial left eye cantus with no ophthalmologic symptoms or pain. The nasal

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1148 endoscopy showed a distorted nasal anatomy with a great enlargement of the middle turbinate and destruction of the inferior turbinate. TC and MR images showed a fronto-ethmoidal mucocele. The patient underwent a navigator system-assisted endoscopic surgery with drainage and marsupialization of the mucocele. Conclusions: Paranasal sinus mucoceles rarely present with visual loss, however a mucocele should be part of the differential diagnosis. Intranasal drainage and marsupializacion of mucoceles using functional endoscopic sinus surgery is the gold standard. Navigator system-assisted endoscopic surgery is useful in case of distorted anatomy, for a safer surgery, and also for teaching purposes.

A406 Garlic, milk thistle, aspirin and epistaxis: beware of complementary and alternative medicine interactions M. Shakeel*, A. Trinidade, N. McCluney, C. Brewis Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK Introduction: A large number of patients take complementary and alternative medicine (CAM) for a variety of reasons, but most do not inform their physicians. This has implications for safety as many forms of herbal CAM are thought to have a variety of side effects and may interact with conventional medicines with potentially adverse consequences. Aim: Highlight the frequent use of complementary and alternative medicine by patients attending the otolaryngology department. To raise awareness of possible interactions between CAM and traditional medicines. Method: We present the case of an otherwise healthy 25-year-old man with difficult-to-control epistaxis. On further questioning, we learnt that he had recently started self-medicating with a combination of aspirin, garlic tablets and milk thistle. Garlic increases bleeding time and milk thistle alters the function of liver enzymes, both of which may have contributed to the difficulty in his management. Results: This case highlights the importance of asking about CAM use when taking a patient’s history, as it may have implications for management.

A407 Hairy polyp of the nasopharynx, an unusual presentation: a case report and literature review Z. AL-Qudehy1*, Y. AL-Nufaily1, H. Yagi2 1 Dammam Medical Complex, Dammam, Saudi Arabia; 2 University of Khartoom, Khartoum, Sudan We report a rare tumor of the nasopharynx with an unusual presentation, in a 15-year-old female: the teratoid or hairy polyp. Hairy polyps are rare benign congenital tumors that present at birth or shortly after. They were reported in the nasopharynx and oropharynx as well. Usually they arise from ectoderm and endoderm. Their presence in older individuals is unusual. Their clinical presentation depends on the site and size. Our patient presented late with nasal obstruction, snoring and mouth breathing, and the clinical examination revealed a nasopharyngeal mass. The tumor was removed without complications and the histopathology was consistent with hairy polyp. In this short communication we raised the awareness about such a rarity which helps to be on the look for

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 it in the appropriate age. A review of this unusual malformation will be included. We believe and after computerized literature search that this is the first report from the Arabian Peninsula.

A408 Indications of ‘‘classic’’ turbinectomy after LASER assisted turbinoplasty in the management of chronic hypertrofic rhinitis R. Duda* ENT Department ‘‘Sfanta Maria’’ Hospital, Bucharest, Romania Hypertrofic rhinitis is a common disorder which appears in general population,especially in allergic patients, impairing significantly their quality of life. The failure of the medical treatment is the most important indication for surgery. Various methods of turbinates reduction are used. The object of this study was to evaluate the neccessity and usefulness of turbinectomy over chronic hypertrofic rhinitis. We studied a number of 133 patients (53 allergic and 80 non allergic) with chronic hypertrofic rhinitis presenting with bilateral nasal obstruction operated on with diode LASER for the turbinates reduction after the failure of medical treatment. We evaluated the reoccurence of the nasal obstruction at 6 months and 1 year. We observed that 16 patients (9 nonallergic, 7 allergic) related the reccurence and then underwent classic surgery. 12% of the patients were reffered for turbinectomy after the failure of LASER treatment, and no significant differences between the allergic and nonallergic group were reported in therms of reoccurence after LASER surgery.

A409 Influence of smoking on endoscopic sinus surgery long-term outcomes R. Chmielewski*, M. Kisiel*, A. Galewicz, A. Krzeski ENT Department, Warsaw Medical University, Warsaw, Poland Objective: The purpose of this study was to explore the influence of smoking on the long-term outcomes of endoscopic sinus surgery for the chronic rhinosinusitis. Methods: The study prospectively enrolled 274 patients of the Department of Otolaryngology-Head and Neck Surgery of Warsaw Medical University, Warsaw, Poland from 1993 to 2000. All patients were diagnosed with chronic rhinosinusitis and were scheduled for the endoscopic sinus surgery. Patients were divided into two groups: smokers (n = 61) and non-smokers (n = 213). Symptoms were evaluated using the Lund-Kennedy scale. After the surgery, severity of the symptoms were compared between the two groups with the follow-up time from 2 to 9 years. Patients with no relief were reoperated. Results: Before the endoscopic sinus surgery, 23.2% of smokers and 20.5% of non-smokers scored III or IV on the Lund-Kennedy endoscopy scale. After the surgery, in 29.5% of smokers symptoms returned. 27 (60%) of the smokers continued smoking after the surgery. Among them, 18 patients were re-operated, which made 66.6% of the total re-operated patients group.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Conclusions: The study shows that smoking had not influence the symptoms before the surgery. Nevertheless, those patients who continued smoking had worse postoperative outcomes.

A410 Inverted papilloma: a diagnostic-therapeutic treatment V. Stojanovic Kamberovic1*, G. Bjelogrlic2*, G. Videnovic3*, M. Bozovic4* 1 Zvezdara Health Center Belgrade, Belgrade, Serbia; 2 Institute for ENT and MFS Clinical Center of Serbia, Belgrade, Serbia; 3School of Medicine Prisˇtina, Clinical for MF Surgery, Kosovska Mitrovica, Kosova; 4Medical Center Uzˇice, Belgrade, Serbia Introduction: An inverted papilloma is a benign lesion characterized by hyperplastic epithelium and its inversion into the underlying tumor stroma, from a microcyte with mucin. Objective: To show a diagnostic-terapeutic treatment in patient with inverted papilloma. Method: Data has been received through anamnesis, a clinical ENT examination, an RTG and CT of the paranasal sinuses. By using FESS the discovered tumefact was removed with PH verification. Case report: A 73-year-old male patient came in for an ENT examination because of many years of obstructed breathing though his nose, without secretion, epistaxis or olfactory problems. An endonasal examination revealed pale rosy colored soft tissue changes with an uneven surface, which obstructed the lower and middle right nasal passage. The PNS RTG did not reveal any pathologic shading of sinuses, but there was a soft tissue shading in the lower right part of the nasal passage, and in the basal part of the left maxillary sinus there was a small amount of thick liquid. There was an endoscopic intervention of the FESS that revealed a tumorous mass in the middle and lower right nasal passage, with an insertion on the lateral wall. By opening the natural opening of the right maxillary sinus, the pathological change was removed completely. Conclusion: An inverted papilloma, a benign lesion of the mucous membrane of the nasal region, frequently with a recidivism and a possible malignant alteration, comprising 0.5–4% of all primary tumors of the nasal region. Keywords: Inverted papilloma, Benign lesion.

1149 Results: The pathology was consistent with mucocele. The patient’s headache disappeared after the operation. Conclusion: Patients with sphenoid sinus lesions should be thoroughly evaluated. Sphenoid sinus operations can be successfully performed by endoscopic transnasal approach.

A412 Lateralized versus birhinal olfactory testing in clinical practice A. Welge-Lu¨ssen1*, V. Gudziol2, M. Wolfensberger1, T. Hummel2 1 Department of Otorhinolaryngology, University Hospital Basel, Basel, Switzerland; 2Smell and Taste Clinic, University of Dresden Medical School, Dresden, Germany Objective: Olfactory tests are usually performed in a birhinal way, usually due to time constraints. Using olfactory screening tests it is known however, that not only patients with tumors but also patients with other olfactory disorders such as chronic rhinosinusitis exhibit side differences in olfactory function. Patients and methods: In 518 patients olfactory function was tested in a lateralized way using the ‘‘Sniffin’ Sticks’’ test battery. Scores for threshold (T), discrimination (D), and identification (I) as well as the composite TDI score were evaluated. Diagnosis of olfactory disorder was made according to history and clinical ENT examination. A side difference was defined as a difference in one of the subtests of 3 or more points or as 6 or more points in the TDI score. Results: Olfactory disorders were classified as post-upper respiratory tract infection (URTI) in 18.7%, posttraumatic (34.2%), sinonasal (11.2%), congenital (3.1%), tumor (1.4%), idiopathic (16.2%) and others (15.1%). In 23.4% of all patients a side difference was noted; as expected, patients with tumors exhibited, on average, the highest degree of side differences. Comparing post-URTI, posttraumatic and sinonasal disorders only post-URTI and posttraumatic disorders exhibited significant differences in threshold. A side difference in threshold correlated with side differences in further subtests and TDI score. Conclusion: In order not to miss unilateral disorders we do recommend to perform threshold tests in a lateralized way. If a side difference is present testing should be continued in a lateralized way, otherwise birhinally.

A411 Isolated sphenoid sinus mucocel S. Ekinci, S. Turkoglu Babakurban*, E. Aydin Department of Otorhinolaryngology, Baskent University Faculty of Medicine, Ankara, Turkey Background: Mucoceles of the sphenoid sinus are rarely seen as 2% of all paranasal sinus mucoceles. In these lesions patients can present with different symptoms such as headache, cranial nerves palsies and nasal symptoms. Objective: We present a case of isolated sphenoid sinus mucocele which presented with headache on the same side of the head. Materials and methods: A 25-five year old female patient, referred to our clinic with headache on the right side of the head. Computed tomography and magnetic resonance imaging studies showed a lesion in the right sphenoid sinus. She underwent endoscopic transnasal sphenoid sinus surgery with removal of the lesion.

A413 Limiting factors in endonasal endoscopic DCR R. Srivastava*, R. Goel, C. Goel Rekha Eye Hospital, Sitapur, Uttar Pradesh, India Objective: The present study was designed to identify the factors which affect the technique, create practical problems, and affect the results in pediatric as well as adult endonasal DCR. Materials and methods: This is the retrospective study of 990 patients (26 pediatric and 964 adult), conducted over the period of 5 years (April 2003 to March, 2008) at Rekha Eye Hospital, Sitapur, Uttar Pradesh, India. The average age of the patients was 7.5 ± 2.8 years in pediatric age group and 33 ± 7.8 years in adults. The male to female ratio in pediatric age group was 1.6:1 and 1:2.74 in adults. All the cases were operated under local anesthesia except 10

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1150 pediatric cases done under general anaesthesia. Bone dissection was done by kerrisons punch in 884 cases (91.7%), and by combination of Gouge, hammer and by otologic drill in remaining 80 (8.3%) cases. Simultaneous septoplasty with endonasal DCR was required in one child and in 44 adult cases. Concha bullosa was excised in 37 adult cases. Intraoperative mitomycin-C was used locally in all paediatric and 864 adult cases. In 6 adult cases orbital fat hindered the proper fashioning of the mucosal flap. Conclusion: The limiting factors in endonasal endoscopic DCR observed in the study are 1. Anatomical variations, such as curvature and thickness of the frontal process of the maxilla, deviated nasal septum, concha bullosa, paradoxical middle turbinate, slightly posteriorly situated lacrimal sac. 2. Damaged common canaliculi, severly fibrosed lacrimal sac due to previous failed external DCR. 3. Atrophic rhinitis.

A414 Long term outcomes of endonasal dacryocystorhinostomy G. Psychogios1*, J. Zenk1, A. Karatzanis1,2, M. Koch1, G. Velegrakis2, H. Iro1 1 Department of Otorhinolaryngology, Head and Neck Surgery, University of Erlangen, Erlangen, Germany; 2 Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete, Crete, Greece Aim: To review the long-term outcomes of endonasal endoscopic DCR (dacryocystorhinostomy) according to our experience. In addition, to evaluate potential prognostic factors for the successful treatment of nasolacrimal duct obstruction with this procedure. Methods: The files of 165 patients who underwent endonasal DCR in our unit between 1991 and 2001 were retrospectively assessed. Furthermore, these cases were clinically evaluated at least 5 years after surgery with the use of nasal endoscopy and nasolacrimal irrigation. In addition, all cases completed a subjective results evaluation questionnaire. Results: A cure was reported by a total of 112 (67.9%) subjects and improvement was noted in 23 cases (13.9%). The total or partial improvement rate was therefore 81.8%. On the other hand, 30 (18.2%) cases were considered as failures. Poor correlation between clinical findings and subjective report of symptoms was found. None of the prognostic factors that were assessed affected outcomes significantly. Conclusion: Long-term success rates for endonasal DCR seem to be comparable to previously published short-term results.

A415 Mandibular advancement splint on treatment of sleep apnea P. Martinez-Seijas*, N. Perez Martin, R. Lobato Perez, U. Bolinaga Zubizarreta, J. Arruti Gonzalez Hospital Donostia, San Sebastian, Spain Objectives: We present the effects of the mandibular advancement splint in adults with obstructive sleep apnea (OSA).

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Materials and methods: We discuss their management for OSA which improves apnea by increasing orofaringeal and hypofaryngeal dimensions. Results: The sample consisted of 125 consecutive cases treated with full tooth coverage that advanced the mandible. Conclusions: Mandibular advanced splint is a suitable alternative to continuous positive airway pressure (CPAP) in the management of mild or moderated sleep apnea. We use in diagnosis (previous orthognathic surgery) and in treatment of sleep apnea.

A416 Massive maxillary polyposis after sinus lift procedure: case report A. Fioretti1*, E. Iacomino1, L. Ventura2, A. Eibenstein1, M. Fusetti1 1 Surgical Sciences Department-ENT, University of L’Aquila, L’Aquila, Italy; 2Department of Pathology, San Salvatore Hospital, L’Aquila, Italy Objective: Some of the most frequent maxillary sinus lift’s postsurgery complications reported in literature are chronic maxillary rhino-sinusitis (1–4.5%), loss of implants (4%), graft infections (2%), loss of graft (1%). We report a rare occurrence of massive maxillary polyposis after sinus lift surgery. Materials and methods: A 50-year-old female come to our observation for a strong pain in the maxillary region after maxillary sinus lift surgery with calcium sulphate and immediate implants placement. CT dentascan revealed the presence of high density material in the maxillary sinus. She also presented an oro-antral communication. Results: After 15 days of medical therapy with FANS and antibiotics, maxillary sinus lift procedure was reviewed and massive polyps obliterating the sinus were discovered and removed with an open classical technique. The wide oro-antral communication was closed with sliding mucosal flap and subsequently the patient experienced a complete resolution of her symptoms. Surgical material was fixed in 10% buffered formalin and consisted of four gray, soft and translucent fragments measuring up to 2.5 cm. One of them was attached to a white fibrous membrane including tiny bone fragments. The histopatological diagnosis was typical inflammatory nasal polyps. Conclusion: An open technique should be the first line of treatment when a massive maxillary polyposis is associated to an oroantral communication secondary to sinus lift procedure. An ENT evaluation with nasal endoscopy and CT scan is always suggested in all candidates for maxillary sinus lift in order to prevent post-operative complications.

A417 Nasal septal abscess due to electro cauterization for epistaxis C. Gantas1*, V. Lachanas1, C. Makrypides1, E. Theos1, M. Chorti2, C. Evaggelopoulos1, G. Karatzias2, E. Gkletsou1, I. Papagiannis2, T. Kaffes2 1 Otorhinolaryngology, Head and Neck Surgery Department, School of Medicine, University of Thessaly,

Eur Arch Otorhinolaryngol (2009) 266:1039–1158

Larissa, Greece; 2ENT Department, General Hospital of Karditsa, Karditsa, Greece Nasal septal abscess is an uncommon entity. The purpose of this study is to report a case of septal abscess as a complication of electro cauterization for epistaxis. Nasal septal abscess following electro cauterization has never been reported so far. A 64 years old woman referred to our department suffering from nasal obstruction and pain since the last 3 days. She referred an episode of right epistaxis 5 days earlier, which has been managed with electro-cauterization. Physical examination revealed a cherry-like swelling of the nasal mucosa emanating from the septum that obstructed both nasal cavities. A complete blood cell count showed a raised total white count of 12900/mm3 and a raised white cell differential count of 88.1% neutrophils. Under local anesthesia, needle aspiration was performed with an 18-gauge needle, and the aspirated pus was sent for culture. Then incision and drainage of the anterior portion of left nasal septum was done. Bilateral nasal Vaseline gauze packing was inserted and removed 48 h later, and intravenous antibiotics were given. After 5 days of antibiotic therapy, the presenting symptoms were totally relieved, and the patient was discharged with continuous use of oral antibiotics for an additional 10 days. The patient was well after 3 months, while no septal perforation, saddle-nose deformity or other complication occurred. Nasal septal abscess is a rare entity, which may very rarely occur after electro cauterization for epistaxis.

A418 Nasopharyngeal cysts T. Marom1*, E. Russo1, D. Ben Salem2, Y. Roth1

Withdrawn

A419 Non-IgE mediated allergic rhinitis: free light chain immunoglobulins M. Kramer1*, D. Powe2, F. Redegeld3

Withdrawn

A420 Our experience in endoscopic management of cranioorbital extended mucoceles M. Nersesyan*, D. Kapitanov, V. Cherecaev, A. Belov, D. Golbin The Burdenko Neurosurgery Institute, Russian Academy of Medical Sciences, Moscow, Russia Objective: Mucoceles of the paranasal sinuses with intracranial and/or orbital extension are relatively uncommon. In the past its treatment in Russia was by an external approach. Our purpose is to present outcomes of 19 patients with cranioorbital extended mucoceles who had

1151 been operated on with endoscopic guidance; establish the etiologic factors which contributed to mucocele formation, describe their clinical presentation, diagnostic evaluation, surgical technique. Methods: Nineteen patients had been operated on endoscopically in our Institute in 2002–2008. The population was composed of 10 males and 9 females, ranging in age from 20 to 70 (mean 42 years old). Mean follow-up was 4.5 years (6 months–6 years). Results and conclusion: Most mucoceles are associated with multiple previous sinus surgeries or neurosurgical procedures on the anterior cranial base region. Intracranial and/or orbital extension of mucoceles are relatively rare, occurring most frequently from the fronto-ethmoidal cells. CT and MRI are imperative for diagnosis, surgical planning, and help decrease the risk of complications. Even in cases of intracranial and/or orbital extension mucoceles are successfully treated with endoscopic guidance. Wide marsupialization is achievable in cases of expanded medial frontal mucoceles. A combined approach may be necessary in lateral frontal sinus mucoceles.

A421 Patients suffering from nasal polyposis showing staphylococcus enterotoxin A and B in serum M. Zivkovic*, M. Krajinovic, L. Janosevic, I. Pendjer Clinical Center Serbia, Belgrade, Serbia Background: Staphylococcus aureus, which produces enterotoxin in about 50% of nasal polyps, induces multiclonal IgE synthesis on the basis of activation of enterotoxin as superantigen. Objective: To examine the presence of specific IgE to SAE A and B in the serum of patients suffering from nasal polyposis. Method: The total of 40 patients (female 15, male 25) with nasal polyposis comprised the examined group. The control group was composed of 10 patients (7 female, 3 male), suffering from chronic rhinosinusitis without nasal polyposis. The serum was treated by the automated method UNI CAP 100 SYSTEM, ‘alergy diagnosis in vivo’ (Pharmacy Uppsala, Sweden). Results: Out of 40 patients with nasal polyposis there were 14/40 (35%), with specific IgE antibodies to SAE A and 8/40 (20%) patients with specific IgE to SAE B, while 8/40 (20%) were positive both to SAE A and SAE B. Patients of the control group (10) have shown no the presence of SAE A and B in the serum. Conclusion: 1. The presence of SAE A or B, or both, is important with patients suffering from nasal polyposis. 2. Our results show that SAE A or B or their combination can have impact on etiopathogenesis of nasal polyposis and prevention of the complications. Reference: 1. Van Cauwenberge P, Gevaert P, Van Hoecke H, Van Zelet, Bachert C (2005) New insights into the pathology of nasal polyposis: the role of superantigens and IgE 2005.

A422 Peculiarities of the pathogenesis of the eustachian tube dysfunction in children’s allergic rhinitis A. Levaya-Smaliak1, E. Merculova 1 Minsk, Belarus Introduction: Intermittent (seasonal) and persistent (all year round) allergic rhinitis (AR) are allergopathologies that are in constant

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1152 interest of otorhinolaryngology. The data concerning the peculiarities of pathogenesis of different forms of AR are not numerous in the literature. Materials and methods: 60 children with different forms of AR were examined: 40 children with intermittent and 20 with persistent form. The examination included the analysis of skin tests, rhinocytograms, subjective otological symptoms, otoscopy data, acoustic impendancemetry, pure tone audiometry, nasal mucociliary transport with the help of ‘‘sugar’’ test and PH value. Statistical data processing performed using test v2. Results: Statistically significant differences of pH value, ‘‘sugar’’ test and peculiarities of skin tests between the groups have not been discovered. The examination of rhinocytograms revealed a common tendency to the infective and inflammatory reaction of the nasal mucosa. In 62.5% of smears with intermittent form and in 40% persistent rhinitis neutrophils have been determined. Eustachian tube dysfunction was diagnosed in each third patient regardless the form of the disease. It proceeded without otological symptoms and had a bilateral character with normal otoscopical pattern. Conclusion: The conducted study showed that the infective and inflammatory reaction of the nasal mucosa, as well as identical frequency and character of disturbance in the middle ear ventilation are typical for all forms of AR.

A423 Rare case of bilateral ethmoid osteomas successfully treated with endoscopic resection A. Trinidade1, M. Shakeel1*, C. Moyes2, B. Ram1 1 Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK; 2NHS Greater Glasgow and Clyde, Glasgow, Scotland Objective: To increase awareness about the clinical presentation and management of ethmoidal and fronto-ethmoidal osteomas. Study design: Case report and review of the literature. Subject: A 56-year old woman presenting with headaches and nasal congestion secondary to bilateral ethmoid osteomas, who made a full recovery following endoscopic resection. Conclusion: Paranasal osteomas are common, benign, encapsulated tumours that are often asymptomatic, but may present similarly to rhinosinusitis and occasionally cause complications depending on their anatomical location. Bilateral ethmoidal osteomas, however, are a rare occurrence and to our knowledge have not been previously reported on in the English literature. Ethmoidal and fronto-ethmoidal osteomas, like other paranasal osteomas, are easily diagnosed using CT and are increasingly amenable to endoscopic resection.

A424 Risk factors for nasal obstruction in preschool children P. Virkkula*, K. Liukkonen, E. Aronen, T. Kirjavainen, A. Pitka¨ranta Helsinki University Central Hospital, Helsinki, Finland Background: Parental smoking, tonsil size and allergy have been related to snoring and sleep apnea in children. These factors may also

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 cause nasal obstruction. Objective measurements are seldom used in evaluation of nasal obstruction in children. Aim of the study: The role of parental smoking, tonsil size and allergy in nasal obstruction was investigated in snoring and nonsnoring children. We also evaluated the relationship between nasal obstruction and snoring frequency or sleep apnea. Children and methods: One hundred and thirteen children 1–6 years of age visited ENT Hospital, Helsinki University Central Hospital. The parents had previously returned a sleep questionnaire. The children underwent clinical examination, acoustic rhinometry, rhinomanometry, skin prick tests and poly-somnography. Results: Low nasal volume or high airflow resistance were not related to increased apnea–hypopnea index or oxygen desaturations. Nor were these measurements influenced by snoring frequency (never—occasionally versus sometimes—every night). Children having a smoking parent had higher nasal resistance than children without a smoker in the family (P = 0.07). This difference was also seen in the subgroup of non-snoring children (P = 0.01). Tonsil size was positively correlated with nasal resis-tance (P = 0.03), whereas skin prick test results were not related to nasal measurements. Conclusions: Parental smoking and tonsil size were found to be risk factors for nasal obstruction in these preschool children. Objective nasal measurements are recommendable for pediatric clinical practise in addition to history of nasal patency.

A425 Selective embolisation in intractable epistaxis in Faculty Hospital Ostrava T. Pniak1*, P. Kominek1, K. Zelenik1, D. Czerny2 1 ENT Clinic, Faculty Hospital Ostrava, Ostrava, Czech Republic; 2Department of Radiology, Faculty Hospital Ostrava, Ostrava, Czech Republic Introduction: Epistaxis is a common ENT emergency that is usually controlled with conservative measures. In refractory or severe cases with possible systemic impact, more invasive methods are needed. Materials and methods: 40-years old men with recurrent posterior epistaxis with insufficient anterior nasal packing has been admitted to ENT clinic. Ballon posterior nasal packing has ben introduced repeatedly, hemoglobin level has decreased to 72 g/l. Angiography revealed source of bleeding in a region of right sphenopalatine artery, microembolisation has been performed succesfully. Some more case reports are used and management of intractable epistaxis in Faculty Hospital Ostrava is described. Conclusion: Selective embolisation is a latter way to control an idiopatic severe epistaxis. It should be used in advance of more aggresive methods, including maxillary and external carotid artery ligation. However, due tu risk of blindness and some other possible morbidity, this method is performed in highly-specialized radiologic centers only.

A426 Septoplasty: surgical outcome and patient benefit S. Vyas*, R. Singh Crosshouse Hospital, Kilmarnock, UK

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Objectives: To assess: 1. Surgical outcome and patient benefit in terms of not only symptom improvement but also over how long a period. 2. If any medical treatment post-op makes any difference to symptomology. Methods: This was an analysis of 368 primary septoplasties for clinically diagnosed deviated nasal septums with associatd symptomology. Majority (80%) were performed with a standard hmitranfixation technique and the rest (20%) were submucus resection. Patients were discharged with either betnesol or otrivine. Results: 95% had great benefit from surgery, 86% of these having improvement within 3 weeks. There was earlier and greater improvement with both betnesol and otrivine initially. Symptoms were assessed via: 1. A symptomology questionnaire covering a 6 week period. 2. Review at the outpatient clinic. Conclusions: Grade of operator (consultant vs. trainee) affected outcome, as well as the position and extent of deviation. Overall, surgery was of great benefit to patients. There was greater improvement with initial post-op treatment with both betnesol and otrivine. However there was no statistically significant difference in symptoms between the 2 groups.

A427 Sleep-disordered breathing evaluation in children C. Martu*, R. Olariu, L. Ungureanu, L. Radulescu ENT Clinic, University of Medicine and Pharmacy, Iasi, Romania There are no available criteria for evaluation of children sleep-disordered breathing. Although the normal polysomnography values in healthy children were established, the different gravity stages of breathing sleep disorders are to be characterized. The aim of this study is to asses the effects of sleep disordered breathing on the behavior and development of children related to the severity of the airway obstruction and the polysomnographic evaluation. Between March and August 2008 we have evaluated 47 children with adenotonsilar hypertrophy or turbinate hypertrophy by overnight polysomnography and clinical examination. The preliminary results show that 31 children out of 38 had: apnea–hypopnea index (AHI) [1 meaning (21 ± 9 s medium period of apnea), overage desaturation was 97% and minimum saturation was bellow 90% in all children and below 70% in 9 children. The relation of the found values to clinical significance is not clear in all cases. The second polygraphic evaluation is to be performed 12 months after surgical or medical treatment. Keywords: Children, Sleep apnea, Polysomnographic

A428 Sphenochoanal polyp: surgical review H. Al Okbi1*, R. Jain2, R. Al-Abri1 Muscat, Oman A sphenochoanal polyp is a very rare lesion that originates in the sphenoid sinus and protrudes through the choana into the nasopharynx. It can occur at any age but is especially common in adolescents and young adults. We present a case of a sphenochoanal polyp in a 7year-old girl who presented with bilateral nasal obstruction and an altered voice. The presentation of a sphenochoanal polyp is similar to

1153 that of the more common antrochoanal polyp, but the two can only be differentiated on cross-sectional imaging (computed tomography and or magnetic resonance imaging). Endoscopic sinus surgery allows for complete removal and minimizes the risk of recurrence.

A429 Study in vivo and in situ by means of videocontact endoscopy concerning the effect of nasal topic steroids associated with nasal functional endoscopic surgery R. Hainarosie*, V. Zainea, I. Postolache, A. Ioan, A. Iliescu, M. Hainarosie, R. Udrescu, I. Stoian, C. Victor, M. Tusaliu IFACF-ORL, Bucharest, Romania The aim of the study is to present some clinical cases and videocontact endoscopy samples concerning with the use of nasal topic steroids associated with functional endoscopic surgery of the nose and sinuses. The method used consists in presenting clinical selected cases which reveals the status in vivo and in situ of the nasal respiratory epithelium in different pathologic situations (allergic rhinitis, smokers, toxic and pharmacologic lesions, iatrogenic lesions). The results obtained following functional endoscopic surgery associated with topic nasal steroids are commented. There is undelined that the air is the natural genetic stimulus of the mucosa line of the respiratory tract, surgical and medical treatment might have in view this obvious true.

A430 Symptoms and signs in 305 patients with chronic rhinosinusitis: correlation and outcome with nasal endoscopy and CT A. Agius* University of Malta Medical School, Guardamangia, Malta The diagnosis of chronic rhinosinusitis is essentially clinical, being based on patient symptoms. Sinus CT has been used as an objective measure of CRS with varying degrees of success and correlation to patient symptoms. Aims: This study aimed to further elucidate the relationship between patient symptoms, nasal endoscopic findings and CT. A cohort of 305 patients with symptoms of CRS that persisted despite maximal medical therapy were evaluated by medical history, clinical examination and nasal endoscopy followed by sinus CT. CT scans scoring 2 or higher on the Lund-Mckay scoring system were classified as positive for sinusitis while scans scoring 0 or 1were classified as negative for sinusitis. 172 scans (56%) were positive while 133 (44%) were negative. Setting: The setting of this study was a busy otolaryngological practice using a computerised database on a small Mediterranean island. Findings: Males with CRS were significantly more likely to have a positive CT (chi squared test, P = 0.0005). Postnasal drip/rhinorrhoea, nasal obstruction and hyposmia as primary symptoms were significantly more likely to be associated with a positive CT (chi squared test, P = 0.0001). Patients presenting with facial pain as the primary symptom were significantly less likely to have a positive

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1154 CT (chi squared test, P = 0.0001). Middle meatal pus or nasal polyps on nasal endoscopy were significantly more likely to be associated with a subsequently positive CT (chi squared test, P \ 0.0001). Patients were followed up for a mean of 2 years and outcomes presented.

A431 The accuracy of pre-operative localization of parotid gland tumours A. Al-Adhami2, M. Shakeel1*, A. Trinidade1, A. Canna2, K. Ah-See1 1 Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK; 2School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK Introduction: It is important for the surgeon to determine whether a lesion is situated within the superficial or deep lobe to decide on the type of parotidectomy. Inaccurate localisation may lead to excessive dissection and increases the possibility of iatrogenic complications. Aim: To assess the accuracy of pre-op localization of parotid gland pathology by comparing it with intra-operative findings. Study design: Retrospective chart review. Ethics: Approved by institutional Clinical Effectiveness department. Method: Data were collected for all patients who underwent parotidectomy in our institution between 1996 and 2007. SPSS v16 was used for data storage and analysis. Results: A total 204 patients were identified, 64% had a preoperative MRI scan, 13% had other type of imaging of parotid gland but the remaining patients did have any pre-op imaging and site localization. There was equal gender distribution with a mean age of 53 years (11–81). Overall there was a poor recording of site of pathology preoperatively as well as per-operatively. Out of 131 cases, 33 did not have accurate site documentation either on MRI scan or in the operation notes. Of 98, 74% of cases had no discrepancy in site localization but in the remaining patients, the predicted lobe involvement did not match with intra-operative findings. Conclusion: The MRI scan findings need to be interpreted with caution. More efforts need to be made to localize the pathology in the parotid gland pre-operatively. This will benefit the patients to have a well planned, safe and appropriate surgical treatment for their condition.

A432 The complications of endoscopic sinus surgery in a residency training program our experience in 192 cases L. Sgambatti*, F. Franco, M. Gil, F. del Rey*, R. de la Fuente, J. del Pozo Hospital Clinico Universitario De Salamanca, Salamanca, Spain Objcetive/hypothesis: Investigate the incidence of complications in endoscopic sinus surgery in a residency training program.

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Study design: Descriptive and retrospective study in tertiary care center. Methods: We reviewed a medical record of endoscopic sinus surgery by nasal polyps of 192 patients who had undergone operations performed by residents in the Department of Otolaryngology-Head and Neck Surgery of the Hospital Clinico Universitario de Salamanca Spain, between January 2002 and January 2008 and describe the sex, age, affectations scale, minor and major complications. All these procedures were performed by residents of 3 or 4 year under the supervision of a faculty member. Results: Of 192 patients, 127 (66.4%) male, 65 (33.85) female, aged between 24 and 78 year old, with a mean age of 49 year old, the polyps extensions of nasal endoscopic showed: grade I 19 (9.8%), grade II 55 (28.6%) and grade III 118 (61.45). We found a 44 (22.9%) of total complications, 40 (20.8%) minors and 4 (2.08%) majors, the most common minor complications was synechia in 21 (10.93%) follow by bleeding without need a transfusion 12 (6.25%), the major complication was a rupture of the papiracea lamina in 4 patients (2.08%). There were no cases of blindness, cerebrospinal fluid rhinorhea, or death. Conclusions: The endoscopic sinus surgery in an otolaryngology residency training program is a relatively safe procedure, especially when they were performed under faculty supervision.

A433 The endoscopic and combined approach to the nasal and paranasal tumors: our first experiences D. Mielcarek-Kuchta*, W. Szyfter ENT Department, University of Medical Sciences, Poznan, Poland Functional endoscopic sinus surgery is a golden standard in the treatment of the chronic sinusitis and some complication of this diseases. However the indications for this type of surgery are still being broadened. For a few years we have observed in the literature the results of endoscopic approach in the treatment of benign and malignant tumors. In the ENT Department University of Medical Sciences in Poznan˜ between the years 1998 and 2008 1,952 patients underwent FESS surgery. In this group 18 patients were operated on because of the benign tumor and 1 due to malignant tumor. There were 6 cases of fibroangioma, 7 of inverted papilloma and 5 osteomas. The four hands technique was the most common method during the surgery. The navigation system was very helpful in the case of tumors located in the skull base area. In all cases the removal of the tumor was possible step by step following the tumor bed. The bleeding was reduced thanks to embolisation performed 3–5 days before the surgery. In some patients combined approach was used because of the local advancement of the tumor.

A434 The etiology of chronic maxillary sinusitis in Yazd M. Vahidi1*, S. Amiri, M. Haidarie, R. Hossain Khanloo 1 Imam Sadegh Hospital Maybod Iran, Yazd, Iran Chronic sinusitis a disease that afflicts a significant percentage of the population and causes considerable long term morbidity. In this study that was descriptive and cross sectional consecutive patients with diagnosis of chronic max. sinusitis (diagnosed with clinical and paraclinical exam for example CT scan) an endoscopically samples of

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 the mucopus of the max. sinuse were aseptically obtained and cultured on aerobes (blood agar, Maconkey) and anaerobes medias. All of the positive cultures were aerobes coagulase negative staphylococci. Enterobacter were the most common isolated organisms and sensitive to bactrim and ciprofloxacin generally. This study was performed in dependent hospital of Shahid Sadoughi Medical University of Yazd. Duration of study was 6 months. Details of study will be presented in conference.

A435 The impact of sinus computed tomography on treatment decisions for chronic sinusitis D. Marev* Department of Otorhinolaryngology, Universiti Hospital ‘‘Sv.Marina’’-Varna, Varna, Bulgaria Objectives: To determine the impact of sinus computed tomography (CT) on treatment decisions by otolaryngologists and to explore the factors leading to choice of surgical treatment for patients suspected of having chronic sinusitis. Design: Prospective cohort study. Setting: A tertiary academic medical center. Patients: Questionnaires were administered to 3 otolaryngologists in a tertiary academic institution regarding diagnosis and treatment decisions in 27 patients suspected of having chronic sinusitis, before and after they reviewed sinus CT scans. Main outcome measures: The dichotomous decisions regarding surgical or nonsurgical treatment and the agreement of treatment decisions among surgeons were evaluated. The factors strongly influencing surgeons’ treatment decisions regarding patients selected for surgery were also determined. Results: The dichotomous treatment decisions were changed in one third of patients (9 of 27) after the sinus CT scans were reviewed. The agreement of treatment decisions among the 3 surgeons was markedly improved after they reviewed sinus CT scans. The factors favorably influencing surgical treatment were obstruction of the ostiomeatal complex on CT and concordance of CT abnormality with a patient’s symptoms. Conclusions: Despite the common belief that treatment decisions for chronic sinusitis should be solely based on clinical grounds, with sinus CT providing only anatomic detail before surgery, our study indicates that the decision to perform surgery was altered by CT in a substantial portion of the patients. In our preliminary study, CT increased the tendency to elect surgical treatment by all 3 surgeons.

A436 The Nasal Congestion Index reflects subjective nasal obstruction T. Kjaergaard1,2*, M. Cvancarova3, S. Steinsvaag1,2 1 Department of Otolaryngology, Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway; 2 Department of Otolaryngology, Head and Neck Surgery, Sørlandet Hospital, Kristiansand, Norway; 3The Norwegian Radium Hospital, National Resource Centre for Long-term Outcome after Cancer, Oslo, Norway

1155 Objectives: The isolated role of mucosal congestion in subjective nasal obstruction remains unclear. A more detailed knowledge of these relations and enhanced diagnostic tools may ultimately improve treatment results due to a better patient selection. Based on the novel Nasal Congestion Index (NCI), we compared subjective nasal obstruction with objective measures for reversible congestion of the nasal mucosa. Study design: 2,523 consecutive patients were included in this cross-sectional study. Eligible subjects were adults referred to the ENT department, Sørlandet Hospital, Kristiansand, Norway, for evaluation of chronic nasal or sleep related complaints. Methods: Acoustic rhinometry (AR) and peak nasal inspiratory flow (PNIF) was performed at baseline and after nasal decongestion. The NCI was based on these registrations, representing the relative differences before and after decongestion. Subjective nasal obstruction was obtained by VAS scales. Statistical analysis was based on ANOVA and multiple linear regression, adjusting for several covariates of importance. Results: The NCI was up to 50% higher in subjects with severe complaints of nasal obstruction compared to subjects with less symptoms (ANOVA, P \ 0.001). The associations were confirmed by multiple linear regression analysis. The NCI for measures of AR and PNIF showed highly significant associations with subjective nasal obstruction (P \ 0.001). Conclusions: We have clearly demonstrated an association between subjective nasal obstruction and reversible congestion of the nasal mucosa by employing the NCI. The measure has proved to be useful for evaluating patients with complaints of nasal obstruction.

A437 The scioeconomical burden of nasal poliposis in Turkey S. Biþkin Erol1*, M. So¨zen1, F. Kayhan2, Y. Uc¸al1, B. Dadaþ1 1 Þiþli Etfal Education and Research Hospital, Istanbul, Turkey; 2ENT Clinic, Baky´rko¨y Dr.Sadi Konuk Education and Research Hospital, Istanbul, Turkey There is no study about the economical costs of the nasal poliposis in the literature. Usually it is investigated under the chronic rhinosinusitis topic. The studies revealed that the operative treatment of rhinosinusitis decreases the overall treatment costs. The aim of our study is to show how the cost of the treatment of nasal polyposis which has a high incidence, effects the country economy and how the surgical treatment decreases this effect, how the clinical amelioration of the patients occurs, how the quality of life the patients changes. As a summary the aim is to evaluate the surgical and medical treatment options from a socioeconomical point of view.

A438 The silent sinus syndrome A. Aleksic*, S. Spiric, P. Spiric, Z. Novakovic, D. Vranjes ENT Clinic, Clinical Centre Banjaluka, BanjaLuka, Bosnia and Herzegovina Silent sinus syndrom is described as a spontaneous painless unilatelar enophthalmus, hypoglobus caused by gradual collapse of orbital floor.

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1156 We present the case of a 34 years old patient with clinical findings showing facial asymmetry caused by unilatelar enophthalmus and hypoglobus of right eye for two months beforehand. Physical examination shows septal deviation and exophthalmometry was 15.5 mm in the right eye and 18 in the left. Radiological findings, CT scans was performed, which revealed volume reduction of right maxillary sinus caused by inward retraction of all sinus walls and increased orbital volume. The patient underwent surgery (Exploratio sinus maxillaris sec Caldwell-Luc) and maxillary sinus mucocele was found and enucleated during the operation. A year and a half after surgical treatment the esthetic results were satisfactory, exophthalmometry is 17 in the right eye and there is no need for reconstruction of the orbital floor.

A439 Treatment of epistaxis with rendu Osler Weber disease: 25 years of experience in a Belgian population R. Mehta*, J. Duterme, M. Barthelemy, J. Duchateau Centre Hospitalier Universitaire Charleroi, Charleroi, Belgium Introduction and aim: Hereditary hemorrhagic telangiectasia (HHT), or Rendu–Osler–Weber syndrome, was first described as a rare condition producing minimal discomfort to affected persons. Now this disorder is considered to be more common and serious than previously thought. This retrospective study aimed to gain more knowledge about the treatment of epistaxis in this disease. Materials and methods: Data of our 19 Belgian HHT-patients’ medical files was collected and reviewed. The clinical diagnosis of HHT was based on the Curacon criteria. Results: All patients had epistaxis as the very first symptom of HHT. Aggravation of the epistaxis with progression of age was noticed by 68.42%. The most common risk factor to provoke epistaxis was sneezing (73.68%), followed by stress (57.89%). More than half our population suffered of arterial hypertension, usually accompanied by epistaxis. Most patients have a history of multiple nasal packings and electric coagulations. The next step in treatment is the Nd Yag laser photo-coagulation, followed by embolisation. Conclusion: Recalcitrant epistaxis is a typical feature of the Rendu–Osler–Weber syndrome, and often the otorhinolaryngologist has to pull out all his tricks to manage the epistaxis. Most of the patients do see an aggravation of the disease with progression of age. Minimal treatment with regular check ups (e.g. detection of anemia) are a must. Patients have to be educated of all possible complications.

A440 Treatment of the nasal polyposis M. Khvadagiani1*, G. Khvadagiani2 1 ORL- Department, Djavakhishvili State University, Tbilisi, Georgia; 2Djavakhishvili State University, Tbilisi, Georgia Introduction: Chronic rhinosinusitis with nasal polyps (CRS with NP) is estimated to affect approximately 5–6% of the population. The aim of the present study is to compare the improvement of symptoms assiciated to CRS with NP 1) After Functional Endoscopic sinus

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 surgery (FESS) and 2) After topical nasal steroid therapy 6 months before and after FESS. Materials and methods: 157 patients with clinically diagnosed CRS with NP participated in this investigation. In all patients FESS (polypectomy, uncinectomy, partial antero-interior middle turbinectomy, antrostomy and complete ethmoidectomy) was performed under control with a 0, 30 and 70 grad endoscopes. Symptoms were recorded on Visual analogs scals before and after three months later the day of surgery (87 patients) and after topical Fluticasone propionate nasal spray (FPNS) therapy (FPNS 200 mg twice daily) for at least 6 months before and after FESS (70 patients). Results: Nasal obstruction was major complaint at entry in the study. Following local steroid course the obstruction score improved significantly. Post-operative normalisation of nasal function was obtained in 65% of first group patients and of 73% of second group. Following surgery and local steorid therapy nasal symptoms were improved more significantly in second group patients, than first group (p’Y 0.05). Conclusion: These data showed that functional endoscopic sinus surgery is effective. FESS is more effective when the patients receive local steroid therapy, FPNS 200 mg twice daily, 3 months before and after surgery.

A441 United airways again: the impact of chronic rhinosinusitis in bronchiectasic patient0 s quality of life J. Guilemany1*, I. Alobid1, S. Centellas1, E. Prades1, A. Obando1, T. Bore´s1, J. Berenguer2, M. BernalSprekelsen1, C. Picado3, J. Mullol1,4 1 Rhinology Unit and Smell Clinic, Hospital Clı´nic Barcelona, Barcelona, Spain; 2Radiology Department, Hospital Clı´nic Barcelona, Barcelona, Spain; 3 Pneumology Department, Hospital Clı´nic Barcelona, Barcelona, Spain; 4IDIBAPS, Barcelona, Spain Background: More than 75% of patients affected with bronchiectasis (BQ) fulfil EP3OS criteria of chronic rhinosinusits (CRS) and 25% nasal polyposis (NP). Objective: To evaluate the impact of CRS on quality of life of patients with BQ, and to correlate these findings with nasal symptoms, pulmonary severity status, and general health status. Methods: In a prospective study, BQ (N = 80) were evaluated for CRS using EP3OS criteria, severity of BQ (HRCT-scan), and lung function using spirometry (FEV1). Quality of life was assessed in all patients by using specific (SNOT-20, SGRQ), and generic (SF-36) questionnaires. Results: Patients with CRS had worse QoL measured by SNOT-20 (2.1 ± 0.1; P \ 0.001), SGRQ (43.7 ± 2.2; P \ 0.001), and SF-36 physical (64 ± 3.4; P \ 0.05) and mental (65.5 ± 4.7; P \ 0.05) summaries than patients without CRS (SNOT-20: 0.4 ± 0.06; SGRQ: 24.7 ± 2.5; SF-36/PS: 76.2 ± 3.3; SF-36/MS: 78.3 ± 5.3), respectively. SNOT-20 score correlated with SGRQ total score (r: 0.72; P \ 0.01), and SF-36 physical summary (r: -0.63; P \ 0.01). SGRQ correlated with SF-36 on physical summary (r: -0.58; P \ 0.05) and with FEV1 (r: -0.41; P \ 0.05). No differences were observed between patients with and without NP. Patients with CRS (6.2 ± 0.5; r \ 0.001) showed higher BQ severity than patients without CRS (4.2 ± 0.7). A mild but significant correlation (r: 0.4; P \ 0.05) was observed between BQ extension and SGRQ score.

Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Conclusion: These findings suggest that CRS with/without NP have a considerable impact on the QoL of patients with BQ. Upper airway QoL have been shown to correlate with both the lower airways QoL, the general health QoL.

A442 Wegener’s granulomatosis presenting as meningitis G. Thiel, M. Shakeel*, K. Ah-See Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK Introduction: Wegener’s granulomatosis (WG) is a rare but well recognized autoimmune necrotizing vasculitis. Presentation of head and neck disease is common and mostly consist of nasal crusting, blockage and bloody discharge. Neurological presentation is very uncommon. As far as we are aware no cases have been reported of presentation with neurological signs without any actual neurological involvement. Methods: We report the case of a patient presenting to the medical emergency services with history of increasing headache over the previous 2 weeks, together with flu-like symptoms and a blocked nose. On the day of admission she complained of severe headache, blurred vision, photophobia and neck stiffness. Her vitals signs were unremarkable except for mild tachycardia. Examination revealed neck stiffness and photophobia, kernig’s was negative, her cranial nerves were grossly intact and her pupils were equal and reactive to light with equivocal fundoscopy. She was admitted to the infectious diseases unit with a provisional diagnosis of meningitis possibly secondary to sinusitis. Literature search was carried out using Medline and Embase, year 1996 to week 32 2007. Search terms were Wegener’s granulomatosis and meningitis. Results: After thorough neurological and medical workup, the combination of CT brain, lumbar puncture nasal biopsy and laboratory test refuted the diagnosis of meningitis and confirmed the diagnosis of Wegener’s granulomatosis. Conclusion: To the best of our knowledge this is the first case report in the English speaking literature of a patient with Wegener’s granulomatosis presenting with symptoms of meningitis without any confirmation by CT scan or lumbar puncture.

A443 What I have learned from about 300 cases of fungal sinusitis T. Abdullah Ashour* King Fahd General Hospital, Jeddah, Kingdom of Saudi Arabia Purpose of the study: To discuss the experience of ENT center, King Fahd Hospital, Jeddah, Saudi Arabia in management of hundreds of cases of fungal sinusitis during the last 20 years. Method and study analysis: Eosinophillic (allergic) fungal sinusitis is a highly aggressive disease affecting the nasal, paranasal sinuses. In our study we will discuss in detail sites, epidemiology, clinical presentation, differential diagnosis, laboratory findings, radiological findings, and management which include preoperative preparation and operative findings and techniques. The postoperative follow up and chances of recurrence.

1157 Results: Allergic fungal sinusitis is a locally destructive disease affecting boundaries between paranasal sinuses and adjacent structures like the eye and brain. Good preoperative preparation and operative and postoperative follow up decrease a lot chance of recurrence. Conclusion: Fungal sinusitis is not uncommon disease in Saudi Arabia especially in humid and high temperature area. Allergic fungal sinusitis is a highly recurrent disease and this depend on the experience of surgeon, intraoperative debridement and postoperative very careful regular follow up to keep the nose and area of drainage of paranasal sinuses always open and intact.

A444 Woakes’ syndrome M. Lobato*, N. Perez*, U. Bolinaga*, E. Perez-Samitier, J. Estefano, J. Algaba Hospital Donostia San Sebastian, Spain Introduction: Woakes0 syndrome was first reported in 1885 by Dr. Woakes as ‘‘necrotising ethmoiditis’’. Case report: 55 year old female patient with aspirin and pirazolone sensitivity, in two times bilateral nasal polyps were surgically removed. She referred nasal obstruction, hyposmia and nasal deformation. Clinically, the nose was extremely broadened with bilateral enlargement of the nasal pyramid of 7 cm. Anterior rhinoscopy showed massive nasal polyps obstructing both nasal sides. CT scan showed a complete obliteration of the paranasal sinuses on both sides with a widening of the ethmoid walls into the orbits. The treatment was surgery by endonasal polypectomy with fronto-spheno-ethmoidectomy and a reconstructive rhynoplasty. Discussion: Woakes’ syndrome is characterized by severe recurrent nasal polyps and broadening of the nose. They are resistant to conventional medical and surgical treatment. The pressure of the polyps produces nasal deformation and hypertelorism. Conclusions: Woakes0 syndrome occurs in chilhood. The nasal polyps expand nasal pyramid and produce hypertelorism. Nasal polyposis are resistant to standard surgical and medical therapies. It is associate with dyscrinia, frontal sinus aplasia, and bronchiectasis.

A445 Anatomic features of the male and of the female larynx in a Brazilian series L. G. Branda˜o, I. C. Ramos, J. S. Branda˜o, C. R. Cernea, A. Junqueira University of Sao Paulo Medical School, Sao Paolo, Brazil Background: According to the available series in the international literature, there are marked anatomic variations in the larynx among the studies involving populations in different geographic areas, which can influence the surgical planning in partial laryngectomies. Objective: To quantitatively evaluate the distances and angles of the larynx in a prospective series of consecutive anatomic dissections in a Brazilian center. Design of the study: Prospective non-randomized cohort study.

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1158 Materials and methods: 35 fresh cadavers (23 male and 12 female; median age: 58.12 year) were evaluated. A cervicothoracic flap was raised. The following biometrical features were evaluated: insertion of vocal folds (VF), thyroid cartilage (TC) angles, and external dimensions of the larynx. Student’s "t" test was used for the statistic analysis. Results: The mean distance between the anterior insertion of VFs and the superior margin of the TC was 10.91 mm in males and 8.41 mm in females. The mean distance between the anterior insertion of VFs and the inferior margin of the TC was 7.43 mm in males and 5.54 mm in females. The angles formed by the laminas of the TC were significantly wider in females. Differences among the present Brazilian study and previous international reports were observed, mainly in the female group. Conclusions: This Brazilian anatomic study offered a quantitative analysis of the biometrical distances and angles of the larynx, which represent crucial landmark structures for the planning of partial laryngectomies. There were statistical differences between the two genders. Moreover, the results of the present series, were different from previously published data from other countries.

A446 Surgical anatomy of the stylomastoid foramen: quantitative measurements L. G. Branda˜o, A. L. Silva, J. S. Branda˜o, C. R. Cernea, A. Jungqueira University of Sao Paulo Medical School, Sao Paolo, Brazil

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Eur Arch Otorhinolaryngol (2009) 266:1039–1158 Background: Operations on the parotid gland (PG) involve identification of the main trunk of the facial nerve (FN) and of its branches. The stylomastoid foramen (SMF) is the point where this nerve exits the skull. A thorough knowledge of its anatomy and of the surrounding landmarks is very important for the head and neck surgeon. Objective: To perform a prospective anatomic study evaluating biometric distances on the region the SMF. Design of the study: prospective non-randomized cohort study. Materials and methods: 15 fresh cadavers (9 male and 6 female), comprising 30 hemifaces, were evaluated. A cervicofacial flap was raised. Measurements in milimeters (mm) were obtained of following segments: tympanomastoid fissure (TMF), styloid process (SP), mastoid tip (MT), facial nerve trunk (FNT) and bifurcation of facial nerve (FNB). PG was gently pulled anteriorly, duplicating a real parotidectomy situation. Pearson test was used for the statistic analysis. Results: The following mean measures were obtained: TMFFNT = 7.50 mm, TMF-FNB = 15.47 mm, SP-FNT = 5.83 mm, SPFNB = 13.73 mm, MT-FNT = 13.30 mm and MT-FNB = 17.13 mm. When Pearson test was applied, the following correlations were found to be statistically significant (P\0.050): FNT-TMF = 7.5 ± 3.17, FNT-MT = 13.3 ± 2.35, FNB-TMF = 15.47 ± 3.99, FNBMT = 17.13 ± 4.26, FNT-SP = 5.83 ± 1.32, FNB-SP = 13.73 ± 2.60; SP-FNT/TMF-FNT = 0.030, SP-FNT/MT-FNT = 0.010, TMFFNT/MT-FNT = 0.043, SP-FNB/TMF-FNB = 0.050, SP-FNB/MTFNB = 0.003, TMF-FNB/MT-FNB B 0.001, TMF-FNB/TMF-FNT = 0.0016. Conclusions: This Brazilian study offered a quantitative analysis of the biometrical distances from the FNT and from FNB to the SMF, which can help the head and neck surgeon to locate the FN, especially in difficult cases.