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Filodiritto Editore – Proceedings
PROCEEDINGS OF
THE NATIONAL ROMANIAN

ENT, HEAD & NECK SURGERY
CONFERENCE
(Craiova, Romania, 11-13 November 2020)
Editor
Serban Vifor BERTESTEANU
FILODIRITTO
INTERNATIONAL PROCEEDINGS
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ISBN 979-12-80225-13-9
DOI: 10.26352/EY11_NATIONAL_ENT-2020
First Edition March 2021
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INDEX
Foreword 10
Quality of Life after Organ Preserving Techniques in Treatment of Laryngeal Cancer 11

BEJENARU Paula Luiza, GRIGORE Raluca, NIȚU Liliana, POPESCU Bogdan,
OANCEA Alina Lavinia, MOȘOIU Anca, SIMION-ANTONIE Catrinel Beatrice,
MUNTEANU Simona-Gloria, CONDEESCU-COJOCĂRIȚA Mihnea,
NICOLAESCU Alexandru, PAUN Oana-Alexandra, CÎRSTEA Anca Ionela,
OTHMAN Amer, NEDELCU Ruxandra Ioana, DIACONU Teodora Elena,
TAHER Bianca Petra, RUJAN Simona-Andreea, SIREȚEANU Luiza Maria,
MITRAN Denisa Maria, OAȘĂ Irina Doinița, FLORESCU Elena,
ANDRONE Roxana, DIMCEA Alisa, POPA Teodora, VETRICEAN Iulia,
MIHALCEA Catalin, TUDOSIE Mihai, MAGDAN Madalin, PAVĂL Cristian,
ENEA Alexandru, COSTIN Romeo, BERTEȘTEANU Șerban Vifor Gabriel
A 3-year-old Boy Burkitt’s Lymphoma Enhancing Otomastoiditis with Facial Palsy 19

BULMACI Mara, DINDELEGAN Maximilian George,
RĂDEANU Doinel Gheorghe, TĂNASE Mihai Ionuț, MANIU Alma Aurelia
A Rare Case of Mucosal Melanoma of the Nasal Cavities 25

CHIOREANU Alexandru, BAȘCHIR Sorin, MORAR Raluca, BOBOC Christian,
POENARU Marioara
Endoscopic Approach of the Frontal Sinus – Anatomical References. Article Review 27

CÎRSTEA Anca Ionela, BERTEȘTEANU Ș.V.G., NIȚU Liliana, POPESCU B.,
OANCEA Alina, IONESCU Diana, SIMION-ANTONIE Catrinel Beatrice,
BEJENARU Paula Luiza, MUNTEANU Gloria Simona,
CONDEESCU-COJOCĂRIȚA M., NICOLAESCU A., OTHMAN A., POPA Teodora,
DIMCEA Alisa, NEDELCU Ruxandra Ioana, DIACONU Teodora Elena,
TAHER Bianca Petra, RUJAN Simona Andreea, SIREȚEANU Luiza Maria,
OAȘĂ Doinița Irina, MITRAN Denisa, FLORESCU Elena, ANDRONE Roxana,
VETRICEAN Iulia, MIHALCEA C.C., TUDOSIE M.D., MAGDAN M.,
PAVĂL C.C., ENEA A.G., COSTIN R., GRIGORE Raluca
Fungal Rhinosinusitis – Diagnostic Aspects, Evolution, Prognosis and Treatment 32

BERTEȘTEANU Șerban Vifor Gabriel, MUNTEANU Gloria Simona,
PĂUN Oana Alexandra, CONDEESCU-COJOCĂRIȚA Mihnea Florin,
BEJENARU Paula, SIMION-ANTONIE Catrinel Beatrice, NIȚU Liliana,
CÎRSTEA Anca Ionela, SIREȚEANU Luiza Maria, DIMCEA Alisa,
NEDELCU Ruxandra Ioana, TAHER Bianca Petra, RUJAN Simona Andreea,
POPA Teodora, DIACONU Teodora Elena, OANCEA Alina,
NICOLAESCU Alexandru, OTHMAN Amer, VETRICEAN Iulia,
MIHALCEA Cătălin Constantin, TUDOSIE Mihai Dumitru, MAGDAN Mădălin,
PAVAL Cristian Costel, ENEA Alexandru Gabriel, COSTIN R., GRIGORE Raluca
3
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Salvage Surgery in Advanced Temporal Region Cancers 38

DINDELEGAN Maximilian George, BULMACI Mara, UJVARY Laszlo Peter,
MANIU Alma Aurelia
Epidemiological, Clinical and Therapeutic Aspects in Odontogenous Sinusitis 45

ENEA Alexandru-Gabriel, MUNTEANU Simona-Gloria, PĂUN Oana-Alexandra,
ANTONIE Catrinel-Beatrice Simion, BEJENARU Paula-Luiza,
CONDEESCU-COJOCARIȚA Mihnea Florin, NIȚU Liliana,
BERTEȘTEANU Șerban Vifor Gabriel, NICOLAESCU Alexandru,
POPESCU Bogdan, MITRAN Denisa Maria, OTHMAN Amer, POPA Teodora,
MOȘOIU Anca, OANCEA Alina Lavinia, RUJAN Simona Andreea,
TAHER Bianca Petra, CÎRSTEA Anca Ionela, OAȘĂ Irina Doinița, FLORESCU Elena,
DIACONU Teodora Elena, DIMCEA Alisa, SIREȚEANU Luiza Maria,
NEDELCU Ruxandra Ioana, VETRICEAN Iulia, TUDOSIE Mihai Dumitru,
TEODORESCU-ARGHEZI Ertan, ANDRONE Roxana, MAGDAN Mădălin,
MIHALCEA Cătălin Constantin, PAVĂL Cristian Costel, COSTIN R.,
GRIGORE Raluca
Flexible Endoscopic Surgery for Glottic Carcinoma in a Patient with

Temporomandibular Joint Ankylosis 53
GURĂU Petru, SENCU Eusebiu, VETRICEAN Sergiu
Universal New-born Hearing Screening: The Experience of Children’s Clinical

Hospital for Children 58
IONESCU Diana, GRIGORE Raluca, BERTESTEANU Serban,
BURUIANA Laura, RUS Olimpia, SOREANU Cristian, HERA Maria Cristina
Borderline Frontal and Ethmoid Osteoma – Full Endoscopic Approach 63

LOSTUN Alexandra, LOSTUN Gabriel Lostun, ȘTEFAN C.,
ȘTEFĂNESCU Dragoș Cristian, HAINĂROȘIE Răzvan
Nasal Wing Foreign Body. Case Report 68

MAGDAN M., BERTEȘTEANU Ș.V.G., GRIGORE Raluca, NIȚU Liliana,
POPESCU B., OANCEA Alina, IONESCU Diana,
SIMION-ANTONIE Catrinel Beatrice, BEJENARU Paula Luiza,
MUNTEANU Gloria Simona, CONDEESCU-COJOCĂRIȚA M.,
NICOLAESCU A., CÎRSTEA Anca Ionela, OTHMAN A., POPA Teodora,
DIMCEA Alisa, NEDELCU Ruxandra Ioana, DIACONU Teodora Elena,
TAHER Bianca Petra, RUJAN Simona Andreea, SIREȚEANU Luiza Maria,
OAȘĂ Irina, MITRAN Denisa, FLORESCU Elena, ANDRONE Roxana,
VETRICEAN Iulia, MIHALCEA C.C., TUDOSIE M.D., PAVĂL C.C.,
COSTIN R., ENEA A.G.
Functional Results of Tympanoplasty with Partial Mastoid Obliteration Due to

Cholesteatoma. Prognostic Factors 73
MANIU Alma Aurelia, BULMACI Mara, DINDELEGAN Maximilian George,
TĂNASE Mihai Ionuț, BLEBEA Cristina Maria, NECULA Violeta
4
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A Particular Clinical Case of Dysphagia in Children 81

MANOLE Felicia, CIAVOI Gabriela, MARGINEAN Emil, VENTER Ciprian,
MOHAN Aurel
Case Report: Laterocervical Adenophlegmon in Children 84

MANOLE Felicia, MARIN Aurel, MARIN Maria Alina, VENTER Ciprian
Larynx Papilomatosis-Diagnosis and Treatment 88

MIHALCEA Cătălin Constantin, MUNTEANU Simona-Gloria,
PĂUN Oana-Alexandra, ANTONIE Catrinel-Beatrice Simion,
BEJENARU Paula-Luiza, CONDEESCU-COJOCARIȚA Mihnea Florin,
NIȚU Liliana, BERTEȘTEANU Șerban Vifor Gabriel, NICOLAESCU Alexandru,
POPESCU Bogdan, MITRAN Denisa Maria, OTHMAN Amer, POPA Teodora,
TAHER Bianca Petra, CÎRSTEA Anca Ionela, OAȘĂ Irina Doinița,
FLORESCU Elena, DIACONU Teodora Elena, DIMCEA Alisa,
SIREȚEANU Luiza Maria, NEDELCU Ruxandra Ioana, VETRICEAN Iulia,
TUDOSIE Mihai Dumitru, TEODORESCU-ARGHEZI Ertan, ANDRONE Roxana,
MAGDAN Mădălin, ENEA Alexandru-Gabriel, PAVĂL Cristian Costel,
COSTIN Romeo, GRIGORE Raluca
Paragangliomas – Therapeutic Management – Review 94

MUNTEANU Simona-Gloria, PAUN Oana-Alexandra, GRIGORE Raluca,
NITU Liliana, POPESCU Bogdan, CONDEESCU-COJOCARITA Mihnea,
SIMION ANTONIE Catrinel Beatrice, BEJENARU Paula Luiza,
CIRSTEA Anca Ionela, OASA Irina Doinita, RUJAN Simona-Andreea,
TAHER Bianca Petra, OTHMAN Amer, VETRICEAN Iulia,
TUDOSIE Mihai Dumitru, NEDELCU Ruxandra Ioana, DIACONU Teodora Elena,
SIRETEANU Luiza, PAVAL Cristian Costel, MAGDAN Madalin,
ENEA Alexandru-Gabriel, MIHALCEA Catalin Constantin, COSTIN Romeo,
BERTESTEANU Serban Vifor Gabriel
Primary Squamous Cell Carcinoma of the Parotid Gland – Case Review 101
NEDELCU Ruxandra Ioana, GRIGORE Raluca, POPESCU Bogdan, NIȚU Liliana,
OANCEA Alina, BEJENARU Paula Luiza, SIMION-ANTONIE Catrinel Beatrice,
CONDEESCUCOJOCĂRIȚĂ Mihnea, NICOLAESCU Alexandru,
CÎRSTEA Anca Ionela, MUNTEANU Gloria Simona, DIACONU Elena Teodora,
DIMCEA Alisa, RUJAN Simona Andreea, SIREȚEANU Luiza Maria,
TAHER Bianca Petra, OTHMAN Amer, POPA Teodora, OAȘĂ Irina,
MITRAN Denisa, FLORESCU Elena, COSTIN Romeo, ANDRONE Roxana,
VETRICEAN Iulia, MIHALCEA Cătălin Constantin, TUDOSIE Mihai Dumitru,
MAGDAN Mădălin, PAVĂL Cristian Costel, ENEA Alexandru Gabriel,
BERTEȘTEANU Șerban Vifor Gabriel
5
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Laryngological Aspects in SARS-CoV-2 Infection 107

OANCEA Alina-Lavinia-Antoaneta, ANDRONE Roxana-Gabriela,
DAYEH Iulia-Irena, OAȘĂ Irina-Doinița, BERTEȘTEANU Șerban Vifor Gabriel,
GRIGORE Raluca, NIȚU Liliana, MOȘOIU Anca, MUNTEANU Simona-Gloria,
BEJEARU Paula Luiza, SIMION-ANTONIE Catrinel Beatrice,
CONDEESCU-COJOCĂRIȚA Mihnea, NICOLAESCU Alexandru,
MITRAN Denisa Maria, FLORESCU Elena Mihaela, CÎRSTEA Anca Ionela,
OTHMAN Amer, POPA Teodora, NEDELCU Ruxandra Ioana,
DIACONU Teodora Elena, TAHER Bianca Petra, RUJAN Simona-Andreea,
SIREȚEANU Luiza Maria, DIMCEA Alisa, VETRICEAN Iulia,
MIHALCEA Cătălin Constantin, TUDOSIE Mihai Dumitru, MAGDAN Mădălin,
PAVĂL Cristian Cornel, ENEA Alexandru, POPESCU Bogdan
Risk Factors of Impaired Wound Healing for Head and Neck Cancer Surgery
After Radiation Therapy 112
OAȘĂ Irina Doinița, BERTEȘTEANU Ș.V.G., GRIGORE Raluca,
OANCEA Alina Lavinia Antoaneta, NIȚU Liliana, MOȘOIU Anca,
MITRAN Denisa Maria, BEJENARU Paula Luiza,
SIMION-ANTONIE Catrinel Beatrice, MUNTEANU Simona-Gloria,
CONDEESCU-COJOCĂRIȚA M., NICOLAESCU A., FLORESCU Elena,
CÎRSTEA Anca Ionela, OTHMAN A., NEDELCU Ruxandra Ioana,
SIREȚEANU Luiza Maria, ANDRONE Roxana, IRENA Dayeh, DIMCEA Alisa,
VETRICEAN Iulia, MIHALCEA C.C., TUDOSIE Mihai, MAGDAN Madalin,
PAVĂL Cristian, ENEA Alexandru, POPESCU Bogdan
Implication of Cumarinic Overdosage in the ENT Sphere 117

PAVĂL Cristian Costel, BERTEȘTEANU Ș.V.G., NIȚU Liliana, POPESCU B.,
OANCEA Alina, SIMION-ANTONIE Catrinel Beatrice, BEJENARU Paula Luiza,
MUNTEANU Gloria Simona, CONDEESCU-COJOCĂRIȚA M., NICOLAESCU A.,
OTHMAN A., POPA Teodora, DIMCEA Alisa, NEDELCU Ruxandra Ioana,
DIACONU Teodora Elena, TAHER Bianca Petra, RUJAN Simona Andreea,
SIREȚEANU Luiza Maria, OAȘĂ Irina, MITRAN Denisa, FLORESCU Elena,
ANDRONE Roxana, VETRICEAN Iulia, DAYEH Iulia-Irena, MIHALCEA C.C.,
TUDOSIE M.D., MAGDAN M., CÎRSTEA A. I., ENEA A.G.1, COSTIN R.,
GRIGORE Raluca
B-Cell Lymphoma of the Sinus Cavities, Case Report 120

POENARU Marioara, MORAR Raluca, BUGARI Radmila, CHIOREANU Alexandru
Difference Between Open Surgery and TOUSS for Oropharyngeal Cancer 122
POPESCU Bogdan, OAȘĂ Irina Doinița, BERTEȘTEANU Ș.V.G.,
GRIGORE Raluca, NIȚU Liliana, MOȘOIU Anca, MITRAN Denisa Maria,
BEJENARU Paula Luiza, SIMION-ANTONIE Catrinel Beatrice,
MUNTEANU Simona-Gloria, CONDEESCU-COJOCĂRIȚA M., NICOLAESCU A.,
FLORESCU Elena, CÎRSTEA Anca Ionela, OTHMAN A., NEDELCU Ruxandra Ioana,
SIREȚEANU Luiza Maria, ANDRONE Roxana, IRENA Dayeh, DIMCEA Alisa,
VETRICEAN Iulia, MIHALCEA C.C.1, TUDOSIE Mihai1, MAGDAN Madalin,
PAVĂL Cristian, ENEA Alexandru, OANCEA Alina Lavinia Antoaneta
6
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Laryngeal Angioedema by Acquired C1 Inhibitor Esterase Deficiency, Case Report 127

RĂDEANU Gheorghe Doinel, BULMACI Mara,
DINDELEGAN Maximilian George, TĂNASE Mihai Ionuț, STAN Constantin,
MANIU Alma Aurelia
Surgical Reconstruction Methods for Head and Neck Skin Defects

after Oncological Surgery 132
RUJAN Simona-Andreea, GRIGORE Raluca, NIȚU Liliana, POPESCU Bogdan,
OANCEA Alina Lavinia, MOȘOIU Anca, TEODORESCU-ARGHEZI Ertan,
SIMION-ANTONIE Catrinel Beatrice, BEJENARU Paula Luiza,
CONDEESCU-COJOCĂRIȚA Mihnea Florin, NICOLAESCU Alexandru,
MUNTEANU Simona-Gloria, CÎRSTEA Anca Ionela, TAHER Bianca-Petra,
SIREȚEANU Luiza-Maria, MITRAN Denisa Maria, OAȘĂ Irina Doinița,
FLORESCU Elena, ANDRONE Roxana, DIMCEA Alisa, NEDELCU Ruxandra Ioana,
DIACONU Teodora Elena, OTHMAN Amer, VETRICEAN Iulia,
MIHALCEA Cătalin-Constantin, TUDOSIE Mihai, MAGDAN Mădalin,
PAVĂL Crtistian-Costel, COSTIN Romeo, ENEA Alexandru-Gabriel,
BERTEȘTEANU Șerban-Vifor-Gabriel
Hearing Impairment in Patients with Cholesteatoma 138

ȘERBAN Roxana, BUTNARU Corina, MERIACRE Tatiana, MÂRȚU Dan,
RĂDULESCU Luminița
Important Anatomical Landmarks of the Orbit for the ENT Surgeon 144
SIMION-ANTONIE Catrinel-Beatrice, BERTEȘTEANU Șerban Vifor Gabriel,
POPESCU Bogdan, NIȚU Liliana OANCEA Alina, MUNTEANU Gloria Simona,
BEJENARU Paula Luiza, CONDEESCU-COJOCĂRIȚĂ Mihnea,
NICOLAESCU Alexandru, CÎRSTEA Anca Ionela, SIREȚEANU Luiza Maria,
DIMCEA Alisa, NEDELCU Ruxandra Ioana, OAȘĂ Irina, RUJAN Simona Andreea,
TAHER Bianca Petra, DIACONU Teodora Elena, OTHMAN Amer,
VETRICEAN Iulia, MIHALCEA Cătălin Constantin, TUDOSIE Mihai Dumitru,
MAGDAN Mădălin, PAVAL Cristian Costel, ENEA Alexandru Gabriel,
PĂUN Oana, GRIGORE Raluca
ENT Manifestations in Systemic Diseases 149

SIREȚEANU Luiza, BERTEȘTEANU Șerban, NIȚU Liliana, POPESCU Bogdan,
SIMION-ANTONIE Catrinel, BEJENARU Paula, MUNTEANU Gloria,
NICOLAESCU Alexandru, COSTIN Romeo, CONDEESCU-COJOCĂRIȚA Mihnea,
CÎRSTEA Anca, OTHMAN Amer, DIACONU Teodora, NEDELCU Ruxandra,
TAHER Bianca, RUJAN Simona, MITRAN Denisa, FLORESCU Elena, OAȘĂ Irina,
DIMCEA Alisa, VETRICEAN Iulia, MIHALCEA Cătălin, TUDOSIE Mihai,
MAGDAN Mădălin, PAVĂL Cristian, ENEA Alexandru, GRIGORE Raluca
Major Reconstruction Following Salvage Laryngectomy – Case Report 154

SPINEANU Ioana-Magdalena, SUCIU Anamaria, POP Septimiu Sever,
MUNTEAN Valentin
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A Rare Case of Parotid Gland Teratoma in a 3 Months Old Patient 158

ȘTEFAN Cătălin, LOSTUN Alexandra, LOSTUN Gabrie,
ȘTEFĂNESCU Dragoș Cristian,
HAINĂROȘIE Răzvan
Features in HPV Positive Oropharyngeal Cancer 163

TAHER Bianca Petra, GRIGORE Raluca, NIȚU Liliana, POPESCU Bogdan,
ANCEA Alina Lavinia, SIMION-ANTONIE Catrinel Beatrice,
BEJENARU Paula Luiza, ANCA Moșoiu, MUNTEANU Gloria Simona,
COSTIN Romeo, CONDEESCU-COJOCĂRIȚA M., NICOLAESCU A., OTHMAN A.,
POPA Teodora, DIMCEA Alisa, NEDELCU Ruxandra Ioana, DIACONU Teodora Elena,
CIRSTEA Anca Ionela, RUJAN Simona Andreea, SIREȚEANU Luiza Maria,
OAȘĂ Irina, MITRAN Denisa Maria, FLORESCU Elena, ANDRONE Roxana,
VETRICEAN Iulia, MIHALCEA C.C., TUDOSIE M.D., MAGDAN M., PAVĂL C.C.,
ENEA A.G., TEODORESCU Arghezi Ertan, BERTEȘTEANU Ș.V.G.
Tracheo-bronchial Foreign Bodies in Tracheostomized Patients. A Review of

the Most Frequent Causes and Treatment Methods 167
TUDOSIE Mihai Dumitru, GRIGORE Raluca, MUNTEANU Gloria Simona,
PAUN Oana Alexandra, CONDEESCU-COJOCARITA Mihnea Florin,
BEJENARU Paula, SIMION-ANTONIE Catrinel Beatrice, NITU Liliana,
CIRSTEA Anca Ionela, SIRETEANU Luiza Maria, DIMCEA Alisa,
NEDELCU Ruxandra Ioana, TAHER Bianca Petra, RUJAN Simona Andreea,
POPA Teodora, DIACONU Teodora Elena, OANCEA Alina,
NICOLAESCU Alexandru, OTHMAN Amer, VETRICEAN Iulia,
MIHALCEA Catalin Constantin, MAGDAN Madalin, PAVAL Cristian Costel,
ENEA Alexandru Gabriel, COSTIN Romeo, BERTESTEANU ȘerbanVifor Gabriel
Submandibular Abscess of Dental Origin and Its Evolution, in Immunosuppressed

and Non-Collaborated Patients. Clinical Case 173
VENTER Ciprian, MĂRGINEAN Emil, POPA Amorin, MANOLE Felicia,
CIAVOI Gabriela, DOMUȚA Maria
Rhinopharyngeal Neoplasm – Distinctiveness of Diagnosis 177

VETRICEAN Iulia, GRIGORE Raluca, MUNTEANU Simona-Gloria,
PĂUN Oana-Alexandra, ANTONIE Catrinel-Beatrice Simion,
BEJENARU Paula-Luiza, CONDEESCU-COJOCARIȚA M.F., NITU Liliana,
NICOLAESCU A., POPESCU B., MITRAN Denisa Maria, POPA Teodora,
TAHER Bianca Petra, CÎRSTEA Anca Ionela, OTHMAN A., OAȘĂ Irina Doinița,
FLORESCU Elena, DIACONU Teodora Elena, DIMCEA Alisa,
SIREȚEANU Luiza Maria, NEDELCU Ruxandra Ioana, TUDOSIE M.D.,
ENEA A., TEODORESCU-ARGHEZI E., ANDRONE Roxana, MAGDAN M.,
MIHALCEA C., PAVĂL C. C., COSTIN R., BERTEȘTEANU Ș.V.G.
The Experience of Otorhinolaringology Department in Surgical Treatment

of Meniere’s Disease 181
VETRICEAN Sergiu, NOROC Iurie
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Limitations in the Treatment of Bulky Malignant Tumours of the Parotid Gland

– Literature Review, Our Clinical Experience 185
VRINCEANU Daniela, DUMITRU Mihai, BANICA Bogdan, SAJIN Maria
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FOREWORD
During the last years, The National Conference in ENT, Head and Neck Surgery has
completely changed the diagnosis and improved many skills and knowledge for the
participants. Its implications in the clinical practice of ENT and the use of more and more
performing instruments and guidelines in cervical and facial surgery, have been materialized
throughout time in numerous meetings and publications.
The Romanian Society of ENT is an old, experienced and dynamic society. The annual
congresses of this society attract in various university cities of Romania an increasingly
higher number of participants and scientific papers. This year, due to global pandemic, the
National Congress was organized exclusively online. Expanding on three days, the meeting
reunited almost 1300 participants and over 80 invited speakers from the country and from
abroad. The congress’ sections included presentations from all hot topics in ENT and Cervical
and Facial Surgery, from updates and new guidelines, to clinical practice and new methods
and treatments.
The representative papers of this congress were proposed for publishing in this volume.
We selected a number of 35 papers that we are sure the reader will find to be significant and
to bring important scientific information consistent in all topics related to ENT.
Editor
Prof. Dr. Șerban Vifor BERTEȘTEANU
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Quality of Life After Organ Preserving Techniques in Treatment

of Laryngeal Cancer
BEJENARU Paula Luiza1,2, GRIGORE Raluca1,2, NIȚU Liliana1,2,

POPESCU Bogdan1,2, OANCEA Alina Lavinia1,2, MOȘOIU Anca1,2,
SIMION-ANTONIE Catrinel Beatrice1,2, MUNTEANU Simona-Gloria1,2,3,
CONDEESCU-COJOCĂRIȚA Mihnea1,2, NICOLAESCU Alexandru2,4,
PAUN Oana-Alexandra5, CÎRSTEA Anca Ionela1, OTHMAN Amer1,
NEDELCU Ruxandra Ioana1, DIACONU Teodora Elena1,
TAHER Bianca Petra1, RUJAN Simona-Andreea1, SIREȚEANU Luiza Maria1,
MITRAN Denisa Maria1, OAȘĂ Irina Doinița1, FLORESCU Elena1,
ANDRONE Roxana1, DIMCEA Alisa1, POPA Teodora1, VETRICEAN Iulia1,
MIHALCEA Catalin1, TUDOSIE Mihai1, MAGDAN Madalin1,
PAVĂL Cristian1, ENEA Alexandru1, COSTIN Romeo3,
BERTEȘTEANU Șerban Vifor Gabriel1,2
1 ENT, Head and neck surgery department, Colţea Clinical Hospital, Bucharest, (ROMANIA)
2 ENT, Head and neck department – “Carol Davila” University of medicine and pharmacy, Bucharest, (ROMANIA)
3 ENT, Head and neck surgery department – “Carol Davila” Emergency Central Military Hospital, Bucharest, (ROMANIA)
4 ENT Clinic MAI Prof. Dr. Dimitrie Gerota Hospital, Bucharest, (ROMANIA)
5 ENT Clinic – Ramnicu – Valcea Emergency Hospital (ROMANIA)
Emails: drpaulabejenaru@gmail.com, berstein@dr.com
Abstract
Introduction/Mean
Although incidence and prevalence are rising, organ preserving therapies that are related to
laryngeal cancer are more accessible nowadays, due to developed technology and better
access to secondary care, especially in dedicated centers. On the other hand, head and neck
oncology implies a significant alteration in the way that the individual is established in the
society with certain ramifications-physical aspect, human interaction disabilities and profound
consequences in quality of life (QoL).
Materials and methods

Retrospective and descriptive study of 40 patients who were admitted in the ENT Clinic of
Coltea Clinical Hospital, Bucharest, with the diagnosis of laryngeal carcinoma, incipient
stages – T1, T2 and selected cases of T3, between 2019-2020. Clinical aspects, investigations,
way of treatment and evolution were evaluated. After discharge, follow-up was made and
with patient’s consent, QoL questionnaire – approved by European Organization for Research
and Treatment of Cancer EORTC QoL C30 – by a telephonic interview was applied.
Results
Surgical treatment was performed by different techniques, from open approach –
laryngofissure with certain types of cordectomies, hemilaryngectomies and reconstruction
procedures, horizontal supraglottic laryngectomy (SGL) – to direct micro laryngoscopy with
cold or electric instruments and even LASER assisted. Global QoL index, functionality and
symptoms auto evaluation was higher after micro laryngoscopy techniques.
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Conclusion
QoL may not be directly linked with clinical and biological assessment of the patient and
new ways of research in multidisciplinary treatment development and applicability can be
sustained by objective tools in QoL evaluation.
Keywords: oncology, larynx, quality of life
Introduction
Quality of life is defined by the WHO as “individuals’ perceptions of their position in life
in the context of the culture and value systems in which they live and in relation to their goals,
expectations, standards and concerns”. [1] It is a broad ranging concept incorporating in a
complex way the persons’ physical health, psychological state, level of independence, social
relationships, personal beliefs and their relationships to salient features of the environment.
[1]
In recent years there has been a broadening of focus in the measurement of health, beyond
traditional health indicators such as mortality and morbidity, to include measures of the
impact of disease and impairment on daily activities and behaviour [2], perceived health
measures [3] and disability/functional status measures [4]. These measures, whilst beginning
to provide a measure of the impact of disease, do not assess quality of life per se, which has
been aptly described as “the missing measurement in health” [5]. HRQoL (health related
quality of life) is more specific and allows medical professionals to appreciate the impact of
disease and treatment on psychological, physical and social aspects [1], [5].
Despite the overall improvement in voice rehabilitation, the presence of a permanent
tracheostomy after total laryngectomy has a negative impact on postoperative quality of life
[6], [7]. There has therefore been an increasing emphasis on laryngeal conservation in the
development of new treatment strategies for patients with laryngeal cancer. Rather than
conservation of the larynx as an organ, the preservation of its function is the ultimate
challenge in these procedures [8].
The EORTC quality of life questionnaire (QLQ) is an integrated system for assessing the
health-related quality of life (HRQoL) of cancer patients participating in international clinical
trials [9]. The core questionnaire, the one that we used in our study – QLQ-C30, is composed
of both multi-item scales and single-item measures. These include five functional scales, three
symptom scales, a global health status/QoL scale, and six single items. Each of the multi-item
scales includes a different set of items – no item occurs in more than one scale. All of the
scales and single-item measures range in score from 0 to 100. A high scale score represents a
higher response level. Thus, a high score for a functional scale represents a high/healthy level
of functioning, a high score for the global health status / QoL represents a high QoL, but a
high score for a symptom scale/item represents a high level of symptomatology/problems.
The scaling technique described above is based upon the widely applied Likert method of
summated scales, in which the constituent items within each scale are simply summed. This
makes several assumptions about the nature of the items, the most important of which are (a)
that it is appropriate to give equal weight to each item, and (b) that each item is graded on a
linear or equal-interval scale. The raw QLQ-C30 scores can be transformed to scores ranging
from 0 to 100. [9]
Material and methods
Retrospective, descriptive study of 40 cases – patients who were admitted to Coltea

Clinical Hospital from Bucharest with a diagnosis of early laryngeal carcinoma. Demographic
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aspects were evaluated and at 6-month follow-up check-up they filled out the EORTC QoL
questionnaire – QLQ-C30. We also analysed clinical aspects, way of treatment and evolution.
To ease the follow-up, we used a telephonic interview to address the patients. Inclusion
criteria was: early stage of the disease; exclusion criteria were any other neuro psychological
or physical impairment that may affect QoL itself and an advanced stage of disease.
Results
Our patients were 95% men – 38 and 5% – 2 women, who were admitted to Coltea Clinical
Hospital between 2019 and 2020, treated with partial techniques for their laryngeal
carcinoma, according to tumour board indication. The interventions summed up: direct
laryngoscopy with cold steel techniques 22% (9 cases); LASER techniques: 25% (9 cases)
endoscopic cordectomy, 1 supraglottic laryngectomy; but also, open techniques – supraglottic
laryngectomy (7%, 3 cases), vertical hemilaryngectomy (23%, 9 cases) and laryngofissure
with cordectomy (23%, 9 cases). Tumour stage was in 70% of the cases stage one (28), in
23% stage two (9 cases) and 3 selected cases of T3 (7%).
QoL index after transoral was: after using LASER techniques 75%, with a 100% physical
activity, as overall role functioning variation between 66 and 83%. As for emotional and
cognitive functioning, patients summed up to 91%. After being treated with cold techniques,
patients related a 66% QoL index with 73% ability to make physical activity, role functioning
up to 83%, but with an emotional and cognitive functioning of 66%, as it is represented in
Fig. 1.
QoL after treatment with transcervical procedures was between 58 and 66% (Fig. 2).
Following vertical laryngectomy, patients described a physical capacity of 53% and a
social integration of 33%. In addition, regarding cognition and emotional functionality, they
had a level of 50-66%. After classic laryngofissure – cordectomy, the physical capacity was at
an average level and associated with a role function of 66% and with an emotional function of
83 and 100%. Open SGL associated a QoL of 66% with a physical functionality of the patient
of 80% and an integrative function of 66%. From a psycho-emotional point of view,
following the analysis of patients' reports, a perception was between 66 and 100%.
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In the symptom’s analysis, the maximum values represent the negative way in which they
affect the individual – a higher score represents a higher level of the problem.
Regarding transoral procedures, patients stated that they did not present financial
difficulties imposed by the treatment. The LASER group reported a score of 33 for insomnia,
dyspnoea, and fatigue, while the trans-orally treated group for other instruments reported a
score of 66 for insomnia, 16 for pain, and 22 for fatigue; for the rest of the questions, the
patients stated that they did not present any symptoms at the time of the interview.
The group treated with vertical laryngectomy stated that they had above average financial
difficulties, insomnia, dyspnoea and pain with a score of 88 and a fatigue of 33. SGL group
reported a score of 33 for financial difficulties, dyspnoea but also a score of 16 for pain. After
laryngofissure – cordectomy, reported symptoms with an impact on QoL only were insomnia
and fatigue.
Discussion
In oncology, survival is the main objective, but the evaluation of the quality-of-life
survival has become indispensable as well as ethnically and economically necessary.
Predicting long term survival based on studies of QoL has been conducted in breast, lung
cancers and more recently in head and neck cancers. [10]
There is debate linked to sex and age as predictive factors for QoL index, with data that
shows that QoL is better in patients older than 65 years or compared to younger patients and
worse in female patients. Other demographic studies show that smoking, depression marital
and employment status also affect QoL. Therefore, socioeconomic status is directly linked to
HRQoL and it should be included as a prognostic factor of morbidity and mortality. [10]
Tumour localization, cancer stage and type of treatment are variables that may influence
QoL – with worse scores especially on QoL eating scale or speech scale. Advanced cancers
are associated with poorer scores, with severe symptoms. [10]
QoL is low during treatment, with changes during the first year of treatment. Impact on
body image, shoulder pain, tracheostomy, multimodal treatment are factors that are enlisted.
HRQoL alteration is particularly distinct among patients who, after having benefited from an
organ preserving protocol, are finally obliged to undergo total laryngectomy. Concerning time
lapse, improvement appears to stabilise 1 year after the completion of treatment. [10]
Functional outcome is affected by difficulties related to diet, feeding – nutritional
disorders, communication, pain and general state of health. Diagnosis and treatment in head
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and neck cancer modify the patient’s individual and social identity. Taboo aspects such as
marital life and sexuality are also affected by diagnosis and treatment of head and neck cancer
– with an increased number of divorces and a reduced sexual activity the first 6 months. [10]
Laryngeal tumours can be treated with a wide diversity of surgical partial resections and
the most standardised partial resections as partial laryngectomies are supraglottic
laryngectomy and supracricoid laryngectomy. The main points of interest are a static and
dynamic functionality, with an ability to minimise aspiration, a near normal voice and an
adequate airway. A literature review relating to swallowing outcome after partial
laryngectomies reveals that for the majority of patients, acceptable feeding can be obtained
without the presence of a permanent tracheostomy. The cricoid cartilage and one functional
cricoarytenoid junction seem to be critical to the preservation of swallowing function and are
anatomical and functional limit in these partial procedures. However, swallowing function is
not often assessed postoperatively in an objective way – only a limited number of studies use
methods such as radiographic images or FESS. Partial laryngectomies benefit from various
types of resection and reconstruction methods used in different institutions. Therefore, it is
outlined that more objective evaluation is needed in this matter to reveal the exact
pathophysiology progression and prognostic factors. [11]
Supraglottic laryngectomy
Supraglottic laryngectomy (SGL) is indicated for lesions of the larynx that are above the
vocal cords and involves a radical end bloc resection of the space between the vocal cords and
tongue base (epiglottis, vallecular, false vocal cords, aryepiglottic folds and in some cases the
hyoid bone) with a reconstruction by primary closure. In some cases, the surgery is extended
to the base of the tongue, pyriform sinus or arytenoid (extended SGL). Steady steps are made
towards LASER and robotic assisted surgery in the last year for cancer that involves the
supraglottic area. Quality of life after this kind of operation is impaired due to swallowing
problems with aspiration phenomena. The most important causes of aspiration are absence of
epiglottic downfolding, increased pharyngeal transit time, delayed closure of the vocal folds
and reduced laryngeal elevation. Spontaneous physiological accommodation is seen over
time, and many studies show that an increased approximation of the arytenoid cartilages to
the base of the tongue, longer duration of lingual-pharyngeal contact, increased peristalsis of
the pharyngeal wall and compensatory mechanism such as a localised hypertrophy of the
inferior lingual base may help this process. [8]
Patients must be aware that there is a considerable time-consuming process to regain
swallowing and complete oral feeding, with good results even after 2 years. Feeding tube
presence, as an important factor involved in QoL index measurement, is maintained between
9 days to even 25 weeks postoperatively. The incidence of postoperative aspiration
pneumonia can be up to 19% of the cases, and aspiration may be subclinical. In these cases, a
total laryngectomy may be required. [8]
Supracricoid partial laryngectomies with variation of reconstruction

These procedures are indicated for tumours that involve the glottis and anterior
commissure, ventricle and paraglottic space with minimal thyroid cartilage invasion. Tumour
invasion in either the hyoid or cricoid cartilage is a contraindication. Resection specimens
must include both true and false vocal cords, the thyroid cartilage and, if necessary, the
epiglottis; at least one arytenoid is spared. The larynx is reconstructed by attaching the
remaining cricoid to either the hyoid (CHP) or the epiglottis (CHEP), resulting in a neoglottis.
As the laryngeal sphincter function is more disturbed in comparison to standard
supraglottic or vertical procedures, aspiration is one of the main problems after surgery. The
postoperative voice is described as weak and fatigued, with limited modulation possibilities,
15
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but patients are considered to have sufficient speech intelligibility. Permanent swallowing
problems may occur in up to 11% of the cases, with rates of postoperative aspiration
pneumonia between 2 and 23%. [8]
Vertical hemilaryngectomy
This kind of surgery requires resection in a vertical plane and involves a frontal or front
lateral portion of the glottis, supraglottis and subglottis. It is indicated for tumours involving
the unilateral vocal fold without contralateral vocal fold invasion of more than one third and
with limited supraglottic and subglottic extension. There are many variations of
reconstruction from primary closure to mucosal false vocal fold flap, cervical skin flap,
sternohyoid muscle flap, thyroid lobe and epiglottoplasty. [8] Thus it is difficult to compare
and standardize postsurgical results. In addition, transoral LASER surgery can address
successfully limited laryngeal tumours. With a high voice preservation, but a suboptimal
range in most patients, aspiration pneumonia and swallowing proficiency is in general slightly
better than after CHEP or CHP. [8]
In conclusion after partial techniques, literature review reveals that swallowing outcome,
as one of the most concerning factors that influence QoL index, is good, with acceptable
feeding obtained without the presence of a permanent tracheostomy. However, it is a long
recovery process, highly dependent on the type and extent of resection. Future consideration
must be taken to standardise well defined and validated instruments to assess impact of
treatment on swallowing and feeding. [8]
Quality of life after HNSCC treatment is generally decreased during treatment, with slow
recovery and main complaints such as decreased physical san role functioning, fatigue,
dyspnoea, insomnia, loss of appetite, financial difficulties, problems with senses and teeth,
limited mouth opening, mouth dryness, coughing and sticky saliva. In Germany, a prospective
study over a 6-month period showed that main predictors linked to variation of QoL index
were tumour stage, well-being and radiotherapy. [12]
In the treatment of early to moderate laryngeal carcinoma, both, transoral laser surgery and
radiation-based protocols have demonstrated good survival and preservation rates. In this
scenario, quality of life (QOL) may become an important tool for treatment planning.
Relevant voice impairment is detected especially in locally advanced tumours, reinforcing the
necessity of preoperative counselling and postoperative rehabilitation. [13]
In our study, overall QoL index was affected by tracheostomy presence, with a
decannulation rate of 41% (9 patients) and the rest of 13 patients still have a tracheostomy 6
months after surgery. Only 15 people (30%) had a nasogastric feeding tube, with a high
variability of probe suppression, from 10 days postoperatively till present (2 cases with
objective aspiration phenomena). Removal time had a mean value of 51 days.
Transoral techniques have better QoL index than transcervical ones, with good outcomes
after using LASER resection, with a good physical, emotional and cognitive functioning.
Voice related in satisfaction was transitory. Better results were achieved after SGL. Insomnia,
dyspnoea, fatigue and pain were the main complaints of the patients, with higher scores in
transcervical group. Also, open techniques were associated with some financial difficulties.
Our study limit is lack of statistic corelation, as we follow-up these patients we hope to
achieve significant results that can be reproduced and help decision making and patient’s
recovery in laryngeal oncological treatment.
Conclusion
Quality of life after organ preserving treatment, following transoral procedures, has a
higher score, with a higher physical, integration and psycho-emotional functionality,
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especially after using LASER instruments. Symptom index showed a higher score in patients
treated with open approach; insomnia, dyspnoea and pain being major among those with
vertical laryngectomies.
In the case of classical open procedures, QoL was reported slightly above average, with
difficulties in social integration, role function of physical effort and greater financial
implications.
Open procedures involve certain complications with an impact on the individual’s quality
of life; sometimes decannulations or even suppression of the nasogastric tube is not possible
due to aspiration phenomena. Quality of life index is dependent on the stage of the disease
and the treatment technique. With proper standardized measurement, it may help in
therapeutic decision and patient’s recovery.
Clinical examination does not always correlate with the patient's general condition. In the
case of surgical procedures for the treatment of laryngeal cancer, there must be a balance
between organ preservation and functionality, with an adequate oncological control of the
disease.
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A 3-year-old Boy Burkitt’s Lymphoma Enhancing Otomastoiditis

with Facial Palsy
BULMACI Mara1,2, DINDELEGAN Maximilian George1,2,

RĂDEANU Doinel Gheorghe1,2, TĂNASE Mihai Ionuț1,2,
MANIU Alma Aurelia1,2
1Department of ENT, Emergency County Hospital, Cluj-Napoca, (ROMANIA)
2Department of ENT, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, (ROMANIA)
Emails: marabulmaci@yahoo.com, maximilian.dindelegan@gmail.com, doinel.radeanu@gmail.com,
dr.mihaitanase@gmail.com, almacjro@yahoo.com
Abstract
Introduction
Primary clinical presentation of Burkitt’s lymphoma with middle ear involvement is
extremely rare in childhood and can be overlooked in the differential diagnosis with more
common infectious ear pathologies.
Methods
In this paper we describe an uncommon case of Burkitt’s lymphoma in a 3-year-old child,
invading the middle ear cleft and mastoid. Although the disease was generalized from the
beginning, the initial symptoms were related only to the ear, mimicking acute mastoiditis
accompanied by facial palsy.
Results
After establishing the correct diagnosis, tumour remission was achieved with six cycles of
chemotherapy.
Conclusion
Physicians should consider a diagnosis of malignant lymphoma if a patient presents with
otitis media and mastoiditis accompanied by facial palsy and use complete neurologic
examination and adequate imaging for an accurate differential diagnosis.
Keywords: acute otomastoiditis, facial palsy, Burkitt lymphoma, histology, diagnosis
Introduction
Burkitt Lymphoma (BL) refers to a high-grade B-cell non-Hodgkin lymphoma

malignancy, which commonly occurs in children. This aggressive neoplasm increases its
tumoral mass faster than any other human tumour. BL usually has constitutional and renal
manifestations. [1] In the head and neck area lymph nodes are the most common sites invaded
by BL, while extra-nodal regions represent less than 25% of cases. [2] The invasion of the
middle ear and mastoids has been reported in only one case of sporadic BL in the past
century. [3]
We report on a BL case in a 3-year-old child, with the involvement of the middle ear and
mastoid with initial symptoms mimicking acute mastoiditis accompanied by facial palsy.
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Case presentation
A 3-year-old boy with no suggestive medical record was referred with left sided earache of
two weeks, hearing loss and facial palsy, not responding to antibiotics and
methylprednisolone (1 mg/kg) for a presumed acute otitis media with mastoiditis.
Examination revealed paleness, bulging in the left mastoid region, and left peripheral facial
nerve palsy. No other neurologic abnormality, nor lymphadenopathy or hepatosplenomegaly
were found. Blood tests revealed no alteration. Temporal bone high-resolution computed
tomography (CT) (GE OPTIMA-540 Siemens (Fig. 1A) demonstrated opacification of the
whole mastoid area and a soft tissue mass enclosing the ossicles. With the suspicion of otitis
media with cholesteatoma, the child underwent an emergency tympanomastoidectomy “canal
wall up” procedure, in order to remove a possible abscess and to decompress the facial nerve.
During surgery no cholesteatoma, but instead severe granulation tissue filling the mastoid
cavity and middle ear and a small amount of pus were found (Fig. 1B).
Fig. 1. Axial CT scan of the left temporal bone demonstrating opacification of the mastoid air cells with a middle
ear mass primarily in the epitympanic region surrounding the ossicles (A). Intra-surgically view of the left ear
revealing diffuse granulation tissue and a mass in the mastoid cavity (B).
The inflammatory tissue was detached almost completely and sent for histopathology. Pus
cultures and Ziehl-Nielsen (ZN) staining were negative. After 7 days abdominal pain and
painful cutaneous nodes in the hairy skin of the head emerged. Cerebral magnetic resonance
imaging (MRI) (GE 360 ADVANCE-3T-Siemens) revealed multiple poorly demarcated
masses, located superficially within the brain parenchyma. (Fig. 2) Contrast-enhanced chest
and abdominal CT showed anterior mediastinal and precranial masses, retroperitoneal lymph
nodes and multiple parenchymal kidney and liver nodes. (Fig. 3) The histological examination
for cerebrospinal fluid (CSF) and bone marrow (BM) revealed no modifications. The testing
for HIV, Epstein-Barr (EBV), B and C hepatitis was negative. Lactate dehydrogenase (LDH)
(360 IU/L, NV 120-300), uric acid (8.2 mg/dL, NV<7) and beta-2 microglobulin (5,6 mg/L,
NV 0.9-2) were elevated.
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Fig. 2. Cerebral MRI – multiple poorly Fig. 3. Contrast-enhanced chest CT –

demarcated masses, less deeply located anterior mediastinal and precranial
within the brain parenchyma. masses
Typical “starry-sky” pattern was exposed from the middle ear granulation mass (Fig. 4A).
Immunohistochemical mark was conclusive for CD10 and CD20 (Fig. 4B), and also CD79,
CD99 and bcl6. CD3 (Fig. 4C), TdT, C-kit a, bcl2 and c-myc were negative. Every single cell
expressed Ki-67 antigen with a proliferative index of 100% (Fig. 4D).
Fig. 4. Biopsy specimen: the monotonous population of small lymphocyte-like cells (“starry sky” pattern) (A).
Biopsy specimen: the monotonous population of small lymphocyte-like cells shows CD20 positivity (B-cell
marker) (B). Cells negative for CD3 (C). Ki-67 expression-proliferative index 100% (D).
Due to the CNS involvement the diagnosis was BL stage IV, according to the St. Jude
staging system. [4] The elevated LDH further contributed to the classification as high-risk. [2]
The patient was initiated on chemotherapy following the trial B-NLH BFM04, R3 with
cerebral involvement (Berlin-Frankfurt-Muenster protocols) [2], consisting in cytarabine
(Alexan: EBEWE Pharma, Austria), vincristine (Gedeon Richter, Hungary), etoposide
(TEVA Pharma, Netherlands), methotrexate (EBEWE Pharma, Austria), ifosfamide (Holoxan
BAXTER – Pharma – Germany/Romania) and leukovorin (PHARMACHEMIE BV –
Netherlands). He received a total of six cycles including intrathecal administration. The 9-
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month follow-up PET-CT showed no residual malignancies. The child is currently free of
symptoms, four years after therapy.
Particularity of the case
Primary clinical presentation of BL in the middle ear is extremely rare. Malik et al., [5]
described the first case in 1976, and since then 9 other cases have been reported in the
literature, including only one sporadic BL case.
Our case highlights that atypical presentation of acute mastoiditis with facial palsy, should
prompt investigation for rare underlying pathologies. As the clinical appearance of
granulation tissue is non-specific, histology and immunohistochemistry remain the only
definitive diagnostic methods.
Discussions
Three types of BL can be distinguished: sporadic, endemic (African), and

immunodeficiency-related (most often HIV-associated). [3] The ENT presentation of BL is
rare in sporadic and immunodeficiency-associated BL. [6] The median occurrence age of
sporadic BL in children is 11. [6] Head and neck involvement was found in 38% of 80
children with BL, in less than ¼ of cases extranodal [7]. Endemic BL account for more than
half of the pediatric malignancies, the median age is 7 years and the jaw involvement
(maxillary and less often mandibular) is frequent [6, 8]. Other types of BL ENT presentations
are given in Table 1.
Table 1. Otorhinolaryngologycal presentations of Burkitt’s lymphoma

Type of involvement Clinical features
Jaw enlargement
Facial bone deformity
Facial bones
Teeth lessening
Peripheral nerve paralysis
Orbital Proptosis, diplopia, occulomotor paralysis
Facial swelling; facial paralysis
Facial tissues
Subcutaneous mass on the cheeks
Ear involvement Ear masses, otorhhea, hypoaccusia, facial paralysis
Waldeyer ring involvement Tonsil mass; sore throat
Nose involvement Nasal obstruction, rhinorrea, anosmia, nose bleeding
Maxillary, spheno-etmoidal pain, rhinorhhea, facial pain, facial

Sinuses involvement deformity, headache
Endoscopically- polypoid mass-like lesion
Oral cavity Gingival infiltration and bleeding
Tongue Difficulty in swallowing, tongue mass
Parapharyngeal space Difficulty in swallowing, reduced hearing, headache
Larynx Dyspnea, stridor, hoarsness
22
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The tumour may arise from the lymphoid tissue layer located profoundly in the epithelium
of mucosa from the tympanic cavity, epitympanum or protympanum. [9] This faster
developing tumour is extremely malignant, destructive and the dissemination is hematogenic.
[2]
The rarity of such tumours makes the diagnosis difficult. A diagnostic protocol should
include cerebral MRI, CT scans of the thorax, abdominal cavity and skeleton. The CSF and
BM must be examined in all patients. [3] Histologically, the “starry-sky” template is a
microscopic trademark of BL.
The differential diagnosis in BL is made with different forms of B-cell lymphoma,
particularly diffuse large B-cell lymphoma. Immunophenotypically BL reveals B-cell lineage
markers, inclusive of CD19, CD20, CD22, CD74, and CD79a, and co-expresses CD10, Bcl-6,
CD43, and p53, without CD5, CD23, Bcl-2, CD138 or TdT. Most of the cells express Ki-67,
similar to our case. Other features are sIg+, and a translocation relating c-myc and IgH or IgL.
[9] BL is among the first human tumours to be causally correlated with EBV, but EBV tests
are usually negative in the sporadic type BL, as in our patient. Having an elevated mitotic
index, BL is intensely responsive to chemotherapy. Cyclophosphamide, cytarabine,
methotrexate in short intensive pulses is used as curative treatment on BL patients associated
with the prophylaxis of CNS, in some cases. Over 90% of children with widespread disease
may achieve complete response. For those presenting with stage IV BL like was our case the
event-free survival rate at 4 years-old is around 79%. [10] The prognostic factors, including
the role of immunity, are not completely defined. Innovative therapies with great efficiency
and minimal toxicity for high-grade-non-Hodgkin lymphoma are awaited. [10] Potential
approaches are ALK inhibitors and the reactive oxygen species (ROS)-modulating
substances. [9] Surgery in BL is rather employed for diagnosis and it has no other role in
therapy. However, in our case, the initial presentation and the lack of clinical lymph node
involvement led to the clinical diagnosis of otitis with mastoiditis, and intraoperatively a
granulation tissue was found.
Although at the time of the surgical intervention the patient likely already had
asymptomatic mediastinal and CNS disease, the initial CT and then the CSF examination
were non-contributive. As otitis media with cholesteatoma is relatively common in children
and facial palsy is not a well-recognized symptom of childhood lymphoma, the definite
diagnosis can be delayed, as in this case. Pediatric malignant ear tumours are rare, but they
present with the same symptoms: otorrhea, otalgia, facial paralysis, and hearing loss. The
differential diagnosis must be made with non-Hodgkin lymphoma, leukaemia, neuroblastoma,
Ewing’s sarcoma, rhabdomyosarcoma and adenoid cystic carcinoma. Eosinophilic ear
granuloma can occur isolated or in systemic Langerhans cell histiocytosis.
REFERENCES
1. Klein E, Klein G: Burkitt lymphoma. Seminars in Cancer Biology 2009; 19 (6): pp. 345-6.
2. Ferry JA. Burkitt’s lymphoma. Clinicopathologic features and differential diagnosis. Oncologist. 2006;
11(4): pp. 375-83.
3. Sandlund JT. Non-Hodgkin lymphoma in children. Curr Hematol Malig Rep. 2015; 10(3): pp. 237-43.
4. Sandlund JT. Burkitt lymphoma: staging and response evaluation. Br J Haematol. 2012 Mar; 156(6):
pp. 761-5. doi: 10.1111/j.1365-2141.2012.09026.x. Epub 2012 Feb 1. PMID: 22296338; PMCID:
PMC3292702.
5. Malik MK, Gupta RK, Samuel KC. Primary lymphoma of middle ear – a case report. Indian J Cancer
1976; 13: pp. 188-9.
6. Sandlund JT, Downing R, Crist WM. Non-Hodgkin’s lymphoma in childhood. N Engl J Med 1996;
334: pp. 1238-48.
7. Anavi Y, Kaplinsky C, Calderon S, Zaizov R. Head, neck, and maxillofacial childhood Burkitt’s
lymphoma: a retrospective analysis of 31 patients. J Oral Maxillofac. Surg. 1990; 48 (7): pp. 708-13.
23
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8. Evens AM, Gordon LI. Burkitt’s and Burkitt-like lymphoma. Curr Treat Options Oncol. 2002; 3(4): pp.
291-305.
9. Paparella MM, El-Fiky F. Ear involvement in malignant lymphoma. Ann Otol Rhinol Laryngol 197281:
pp. 352-63.
10. Nakamura N, Nakamine H, Tamaru J, Shigeo Nakamura, Tadashi Yoshino, Kouichi Ohshima et al. The
distinction between Burkitt lymphoma and diffuse large B-cell lymphoma with c-myc rearrangement.
Mod Pathol 2002; 15: pp. 771-6.
24
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A Rare Case of Mucosal Melanoma of the Nasal Cavities
CHIOREANU Alexandru1, BAȘCHIR Sorin1, MORAR Raluca2,

BOBOC Christian2, POENARU Marioara1
1“Vasile Goldis” Western University Arad, Otolaryngology department, Arad, Romania, (ROMANIA)
2“Victor Babeș” University of Medicine and Pharmacy Timișoara (ROMANIA)
Emails: alexandru.chioreanu@yahoo.ro, sorinbaschir@yahoo.com, ralu_morar@yahoo.com,
marioara.poenaru@gmail.com, knightsirc@gmail.com
Abstract
Mucosal malignant melanoma is a very rare disease, accounting for less than 3% of all
melanomas (1, 2). Patients usually present a brown tumour located in the nasal cavity with a
history of nasal blockage, epistaxis and faulty smell. Case report: a 58-year-old female
accusing nasal blockage on the left side and epistaxis for about 6 months. Nasal endoscopy
revealed an exophytic tumour having a pink colour, situated on the upper side of the nasal
cavity blocking the anterior 1/3 of the cavity. On CT scan, the tumour was located only on the
left nasal cavity.
A grossly excision of the tumour was practiced, thru endoscopic surgery. Biopsy revealed
a nodular melanoma, the tumoral cells were S100, melan A and HMB45 positive and negative
for CD99, PFP9.5 and synaptophysin.
Keywords: Nasal melanoma, melan A, rare tumours
Introduction
Mucosal malignant melanomas present symptoms such as progressive nasal obstruction,

epistaxis and in some cases facial deformities (3, 4). Most of the times they are found by
accident in CT or MRI scans or in nasal endoscopy. Diagnosis in later stages of the disease is
common because of the non-specific symptomatology, making it even harder for a treatment
to be 100% curable (5, 6).
Case report
We present a case of a 58-year-old woman that accused nasal blockage on the left side
alongside rare and intermittent epistaxis. At a first nasal endoscopic examination a unilateral
nasal mass was growing from the middle and upper meatus. It had a pink-white colour,
smooth texture, and did not bleed upon nasal aspiration.
The tumour has been removed under endoscopic control and had been sent to the
histopathological examination. The anatomo-pathological exam revealed the presence of a
malignant tumour proliferation consisting of nests of large polyhedral cells, with eosinophilic
cytoplasm, poorly represented quantitatively and enlarged nuclei in volume, vesicular, with
unequally distributed chromatin pattern and multiple eosinophilic macronucleoli. The
immunohistochemistry exam showed that the tumour cells were positive for S100 protein,
Melan
A and HMB45 and negative for synaptophysin, CD99, PGP9, BAP 1 positive and negative
AE1/AE3 and CD117 markers. It concluded that it was a nodular amelanotic melanoma with
epithelioid cells. The patient was referred to oncology for further treatment.
25
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Discussions
Most mucosal melanomas have a nonspecific set of symptoms that can mislead and set the
ENT specialist on a wrong diagnosis. Fortunately, in most cases biopsy should put a positive
diagnosis and the patient could benefit from a proper treatment plan.
Even with full resection of the tumour, mucosal melanomas have a very aggressive
evolution and tend to recur alongside metastasis in different parts of the body (7, 8).
Conclusions
Early detection is the best solution when it comes to the evolution of mucosal melanomas.
Surgery within safe margins alongside immunotherapy and chemotherapy should be
performed for a better outcome.
REFERENCES
1. Sarău CA, Poenaru M, Balica NC, Baderca F., 2017, Rare sino-nasal lesions. Rom J Morphol Embryol,
58(4): pp. 1541-1547.
2. Karim MU, Khan K, Ali N, Ikram M., 2015, 2015, Sino-nasal mucosal malignant melanoma. BMJ Case
Rep.: bcr2014206745. Published 2015 Apr 29. doi:10.1136/bcr-2014-206745
3. Gore MR, Zanation AM., 2012, Survival in Sino-nasal Melanoma: A Meta-analysis. J Neurol Surg B
Skull Base.; 73(3): pp. 157-62.
4. Bhide SA, Newbold KL, Harrington KJ, Nutting CM., 2012, Clinical evaluation of intensity-modulated
radiotherapy for head and neck cancers. Br J Radiol.; 85(1013): pp. 487-94.
5. Mioc, ML., Prejbeanu, R., Vermesan, D. et al., 2018, Deep vein thrombosis following the treatment of
lower limb pathologic bone fractures – a comparative study. BMC Musculoskelet Disord 19, 213.
6. Pop DL, Folescu R, Deleanu BN, Iacob M, Vermeşan D, Prejbeanu R, Maliţa DC, Hărăguş HG, Ciupe
BC, Zamfir CL, Nodiţi G., 2018, The role of immunohistochemistry in the diagnosis and management
of synovial sarcoma. Rom J Morphol Embryol.; 59(2): pp. 569-572. PMID: 30173264.
7. Moţ IC, Poenaru M, Mogoantă CA, Istrate-Ofiţeru AM, Oprişcan IC, Sarău CA, Mănescu MD,
Enăchescu V, Dogaru CA, Popescu C, Morar R, Balica NC, Horhat ID., 2019, Head and neck
metachronous tumours – clinical, histopathological and immunohistochemical study. Rom J Morphol
Embryol.; 60(4): pp. 1199-1206. PMID: 32239095.
8. Muntean D, Horhat F-G, Bădițoiu L, Dumitrașcu V, Bagiu I-C, Horhat D-I, Coșniță DA, Krasta A,
Dugăeşescu D, Licker M., 2018, Multidrug-Resistant Gram-Negative Bacilli: A Retrospective Study of
Trends in a Tertiary Healthcare Unit. Medicina.; 54(6): p. 92.
https://doi.org/10.3390/medicina54060092
26
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Endoscopic Approach of the Frontal Sinus – Anatomical

References. Article Review
CÎRSTEA Anca Ionela1,2, BERTEȘTEANU Ș.V.G.1,2, NIȚU Liliana1,2,
POPESCU B.1,2, OANCEA Alina1,2, IONESCU Diana1,5,
SIMION-ANTONIE Catrinel Beatrice1,2, BEJENARU Paula Luiza1,2,
MUNTEANU Gloria Simona1,2,3, CONDEESCU-COJOCĂRIȚA M.1,2,
NICOLAESCU A.1,2,4, OTHMAN A.1, POPA Teodora1, DIMCEA Alisa1,
NEDELCU Ruxandra Ioana1, DIACONU Teodora Elena1,
TAHER Bianca Petra1, RUJAN Simona Andreea1, SIREȚEANU Luiza Maria1,
OAȘĂ Doinița Irina1, MITRAN Denisa1, FLORESCU Elena1,
ANDRONE Roxana1, VETRICEAN Iulia1, MIHALCEA C.C.1, TUDOSIE M.D.1,
MAGDAN M.1, PAVĂL C.C.1, ENEA A.G.1, COSTIN R. 6, GRIGORE Raluca1,2
1 ENT Department – Coltea Clinical Hospital (ROMANIA)
2 “Carol Davila University of Medicine and Pharmacy” (ROMANIA)
3 ENT Department – Dr. Carol Davila Central Military Emergency University Hospital (ROMANIA)
4 ENT Department – Prof. Dr. Dimitrie Gerota MI Hospital (ROMANIA)
5 Dr. Victor Gomoiu Children’s Hospital (ROMANIA)
6 Central Military Emergency Hospital Dr. Carol Davila, Bucharest, (ROMANIA)
Email: cirsteaancaa@gmail.com
Abstract
Introduction
The frontal sinus is a pneumatized space in the frontal bone that develops from the anterior
ethmoid. The complexity of the frontal recess determines a difficult endoscopic approach of
the frontal sinus, performed only by experienced surgeons, requiring detailed knowledge of
the anatomy at this level. [1]
Methods
We used the literature available in English that addresses the anatomy and endoscopic
surgery of the frontal sinus. Also, consulting the main medical databases (NCBI®, Cochrane®)
we evaluated recent studies that focus on the anatomical variations of the frontal recess.
Results
The anatomy of the frontal recess can be extremely variable from patient to patient. The
size and configuration of the frontal recess depend on a number of structures: uncinate
process, agger nasi, ethmoidal bulla, other ethmoidal cells located at the frontal recess. [3]
A number of vital structures are found nearby, such as: the cribriform plate, the olfactory
fibres, the anterior ethmoidal artery and the anterior nasal artery. [4]
Conclusions
The delicate bone structures and the mucosa at the level of the frontal recess, require a less
traumatic approach, in order to avoid granulations, scars and stenoses that can cause problems
of the frontal sinus that the patient did not have before the intervention. Careful planning of
endoscopic intervention based on the study of each patient's anatomy is required for a safe
and successful approach. [5]
Keywords: frontal sinus, endoscopy, anatomy
27
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Introduction
The frontal sinus is a pneumatized space in the frontal bone that develops from the anterior
ethmoid. The complexity of the frontal recess determines a difficult endoscopic approach of
the frontal sinus, performed only by experienced surgeons, requiring detailed knowledge of
the anatomy at this level. [1] The variable anatomical development of the frontal sinus and its
anterior superior location within the nasal cavity increase the possibility of disorientation
during surgery.
Prior to surgery, a well-performed CT scan with sagittal and coronal views must be
obtained, to help the surgeon identify the main landmarks, in order to avoid them. In order to
increase the accuracy of intraoperative anatomical landmarks, navigation systems can be used.
[2]
We used the literature available in English that addresses the anatomy and endoscopic
surgery of the frontal sinus. Also, consulting the main medical databases (NCBI®, Cochrane®)
we evaluated recent studies that focus on the anatomical variations of the frontal recess. The
pictures used belong to the ENT Department of the Coltea Clinical Hospital.
Results
Gross anatomy of the frontal sinus

The frontal sinuses are two in number and are located in the thickness of the frontal bone.
They are the result of invasion of ethmoid air cells in the frontal bone. The air cell invasion
begins at the level of the frontal ostium, then continues at the level of the infundibulum and is
maximum at the level of the frontal sinuses. The infundibulum, the ostium and the frontal
sinus have the shape of an hourglass in the sagittal plane.
The frontal sinuses are separated by a thin oblique bone wall and may be asymmetrical or
septate.
The anterior wall is made of diploic bone and is the thickest, having about 4 mm. The
posterior wall is thin and is closely related to the posterior cerebral fossa. The inferior wall is
related to the anterior ethmoid cells and participates in the formation of the roof of the orbit.
The posterior wall is thin and is closely related to the posterior cerebral fossa. the orbit.
The frontal sinus drains into the anterior part of the middle meatus through the frontonasal
duct. [12-17]
Necessary tools
The approach to the frontal recess is the most difficult and risky stage in all endoscopic
surgery. The frontal recess is usually opened using a 45° telescope. The most useful tools are
angled instruments, such as Kuhn-Bolger giraffe forceps, angled curettes, Blaskesley-Weil
nasal forceps, Stammberger circular-cutting-punch, angled suction. [3], [4]
The head of the patient must be tilted backwards to facilitate exposure.
Endoscopic anatomy
The anatomy of the frontal recess can be extremely variable from patient to patient. The
size and configuration of the frontal recess depend on a number of structures: uncinate
process, agger nasi, ethmoidal bulla, other ethmoidal cells located at the frontal recess. [5]
A number of vital structures are found nearby, such as: the cribriform plate, the olfactory
fibres, the anterior ethmoidal artery and the anterior nasal artery. [6]
28
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The main landmarks to be identified are: insertion of the middle turbinate at the lateral
wall, lamina papyracea, middle turbinate, anterior wall of the bulla ethmoidalis (Fig. 1), relief
of the anterior ethmoidal artery.
Fig. 1. The middle turbinate medialized

and the bulla ethmoidalis (blue circle)
The ethmoidal infundibulum leads to the frontal recess, here the natural drainage of the
frontal sinus is achieved. A simple infundibulotomy is often sufficient to relieve obstructed
drainage from the frontal sinus. If an enlargement of the frontal recess is necessary, the
anterior wall of the frontal sinus (formed by the Agger nasi) is removed, followed by
reduction of the anterior border of the middle turbinate. The various drainages of the frontal
sinus are classified by Draf into three types:
• Draf I: is represented by ethmoidectomy including cell septa in the region of the
frontal recess. The landmark considered to be safe in this type of surgery is the lamina
papyracea.
• Draf II: the ethmoidectomy is followed by resection of the floor of the frontal sinus
between the lamina papyracea and the middle turbinate (type IIa) or the nasal septum
(type IIb) anterior to the ventral margin of the olfactory fossa. For the type IIa the
landmark here is the arch formed by the passage between the medial aspect of the
frontal maxillary process and the lateral aspect of the insertion of the middle turbinate.
For the type IIb the landmark is the olfactory nerve, its identification is necessary so as
not to damage the olfactory cleft.
• Draf III (modified endoscopic Lothrop procedure): requires the resection of the medial
floor of both frontal sinuses, the intersinus septum and the superior nasal septum. The
anterolateral and dorsocranial landmarks are the lacrimal sac and the first olfactory
nerve. [6-9]
In the Fig. 2 we can see the 0° endoscopic view of the drilled frontal maxillary process on
the left side and the insertion of the middle turbinate on the right side. To identify the
frontonasal duct the Agger nasi was removed.
Figure 2 shows the frontal sinus with a 45-degree endoscope.
In the Fig. 4 it is shown the 0-degree view of a frontal sinus at 3 months after a Draf II
surgery.
29
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Fig. 2. Drilled frontal maxillary process Fig. 3. 45° view of the frontal sinus
(left side) and insertion of the middle
turbinate (right side) – 0°.
Fig. 4. 0° view of the frontal sinus after

Draf II – 3 months after surgery.
Conclusions
The delicate bone structures and the mucosa at the level of the frontal recess, require a less
traumatic approach, in order to avoid granulations, scars and stenoses that can cause problems
of the frontal sinus that the patient did not have before the intervention. Careful planning of
endoscopic intervention based on the study of each patient's anatomy is required for a safe
and successful approach.
Identifying landmarks is essential for intraoperative orientation and to avoid damaging
vital structures.
REFERENCES
1. Hosemann, W., Kuhnel, T., Weber, R. (2020). Anatomy of the paranasal sinuses and the anterior skull
base – Fundamentals of Endoscopic Endonasal Surgery. Embryology, Biological Benefit and Key
Structural Features of the Paranasal Sinuses (1), pp. 9-13.
2. Eliashar R, Sichel J, Gross M, et al., Image guided navigation system – a new technology for complex
endoscopic endonasal surgery Postgraduate Medical Journal 2003; 79: pp. 686-690.
3. Leunig A (2007). Endoscopic surgery of the lateral nasal wall, paranasal sinuses and anterior skull base:
principles and clinical examples. Karl Stortz, Tuttlingen, Germany.
4. Stammberger H (1991). Functional endoscopic sinus surgery: the Messerklinger technique. Decker,
Philadelphia, Pa.
30
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5. Lal, D., Stankiewicz, J.A. (2015). Cummings Otolaryngology. Primary Sinus Surgery (49), pp. 752-
760.
6. Combined approach for large tumours of the nose and paranasal sinuses – case report, O. D. Palade,
2016, Vol. 1 (20), pp. 380-383.
8. Alsaied, A.S. (2016): Paranasal Sinuses. Paranasal Sinus Anatomy: What the Surgeon Needs to Know.
9. Draf W. (2005) Endonasal Frontal Sinus Drainage Type I-III According to Draf. In: Kountakis S.E.,
Senior B.A., Draf W. (eds) The Frontal Sinus. Springer, Berlin, Heidelberg. https://doi.org/10.1007/3-
540-27607-6_24
10. Paolo Castelnuovo (2008), Endoscopic cadaver dissection for teaching anterior skull base surgery.
EndoPress; Germany, pp. 33-41.
11. Significance of serum antibodies against HSP 60 and HSP 70 for the diagnostic of infectious diseases
by: Bleotu, Coralia; Chifiriuc, Mariana Carmen; Pircalabioru, Gratiela; et al., VIRULENCE Volume: 5
Issue: 8 Pages: 828-831 Published: NOV-DEC 2014.
F, Preda MA, Iovan VC, Stanca HT (corresponding author), Busuioc CJ, Oprişcan IC, Boruga O. Rom J
https://doi.org/10.1155/2020/3526316.
14. Clinical outcomes of micropulse transscleral cyclophotocoagulation in refractory glaucoma – 18 months
follow-up. Preda, M.A., Karancsi, O.L., Munteanu, M., Stanca, H.T. Lasers in Medical Science (2020)
https://doi.org/10.1007/s10103-019-02934-x.
Embryol. 2018; 59(1): pp. 113-119; ISSN 1220-0522 (print) ISSN 2066-8279 (online).
https://doi.org/10.3892/etm.2019.7857.
doi: 10.3892/etm.2019.7635. Epub 2019 May 31.
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Fungal Rhinosinusitis – Diagnostic Aspects, Evolution, Prognosis

and Treatment
BERTEȘTEANU Șerban Vifor Gabriel1,2, MUNTEANU Gloria Simona1,

PĂUN Oana Alexandra3, CONDEESCU-COJOCĂRIȚA Mihnea Florin1,2,
BEJENARU Paula1, SIMION-ANTONIE Catrinel Beatrice1, NIȚU Liliana1,2,
CÎRSTEA Anca Ionela1, SIREȚEANU Luiza Maria1, DIMCEA Alisa1,
NEDELCU Ruxandra Ioana1, TAHER Bianca Petra1, RUJAN Simona Andreea1,
POPA Teodora1, DIACONU Teodora Elena1, OANCEA Alina1,2,
NICOLAESCU Alexandru1,2, OTHMAN Amer1, VETRICEAN Iulia1,
MIHALCEA Cătălin Constantin1, TUDOSIE Mihai Dumitru1,
MAGDAN Mădălin1, PAVAL Cristian Costel1, ENEA Alexandru Gabriel1,
COSTIN R.4, GRIGORE Raluca1,2
1 U.M.F. “Carol Davila” Bucharest – Faculty of General Medicine – ENT Department (ROMANIA)
2 “Colţea” Clinical Hospital – ENT Department (ROMANIA)
3 “Vâlcea” County Emergency Hospital – ENT Department (ROMANIA)
Email: Teodora_Diaconu28@yahoo.com
Abstract
Introduction
Fungal rhinosinusitis is a general term used to define a wide range of pathological
responses, including invasive, chronic, granulomatous, and allergic diseases, with an
increased prevalence in recent decades. The presentation is chronic, but it can also be acute,
which, although rare, is important due to its aggressive evolution and high mortality rates
(from 50% to 80%).
Methodology
The cases presented emphasize the two antagonistic clinical presentations: acute versus
chronic. A patient who showed no clinical symptoms, the discovery being incidental after a
panoramic dental x-ray. The other patient who was known to have multiple comorbidities
presented with an altered general condition and had a fulminant course of the disease. The
cases highlight important clinical findings, diagnostic algorithm, surgical management and
prognosis.
Conclusion
It is fundamental to deepen the elements of positive and differential diagnosis for fungal
rhinosinusal pathology. Thus, it is possible to intervene early, with positive consequences on
the patient’s prognosis and evolution.
Keywords: fungal, invasive, non-invasive rhinosinusitis, fungi, rhinosinusal pathology
32
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General presentation
Fungal rhinosinusitis is a general term used to define a wide range of pathological

responses, including invasive, chronic, granulomatous, and allergic diseases, with an
increased prevalence in recent decades.
Fungal rhinosinusitis has two distinct forms of presentation: invasive fulminant disease
that usually occurs in immunocompromised patients and chronic, non-invasive fungal
rhinosinusitis in seemingly healthy patients.
Aspergillus species are most commonly isolated in cases of chronic rhinosinusitis, but
other species have also been identified such as Dematiaceous hyphomycetes, Pseudallescheria
boydii, Candida spp., Fusarium spp., Hyalohyphomycetes. Regarding the invasive form, the
most common is mucormycosis. Mucormycosis is a term used to describe the pathology
caused by any fungal species of the order Mucorales, class Zygomycetes. It is the fastest
invasive and the most fatal fungal infection of the sinuses. It shows a very fast growth, in 24
hours the cultures appear on the Petri dish. Patients with uncontrolled diabetes, particularly
those with diabetic ketoacidosis are at risk for invasive mucormycosis. This species has
vascular invasiveness with obstruction of blood vessels that quickly leads to ischemia and
necrosis.
Fungi are ubiquitous in the environment with over 1.5 million species. Having such a
spread, human exposure is inevitable, with each breath the storage of fungi in the nasal cavity
and paranasal sinuses. In most cases, the presence of fungi has no clinical consequences.
First case
An 84-year-old patient, known with unbalanced type 2 diabetes, essential hypertension,
ischemic cardiomyopathy, stroke, therapeutically neglected. He presented to the ENT Clinic
for the appearance of a swelling in the right cheek, started a week ago, with evolution to
necrosis, chronic right nasal obstruction, purulent rhinorrhoea and cacosmia. The general
condition of the patient was altered at presentation.
Fig. 1. Clinical aspect
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Fig. 2. Clinical aspect
Fig. 3. Intraoperative endoscopic appearance
At the clinical examination, an area of necrosis was observed on the right cheek of about
3/3 cm, lack of substance on the hard palate, of about 2/2 cm. Nasal endoscopy revealed the
exteriorization of necrotic material and viscous secretions from the middle meatus.
An emergency sinus CT scan was performed that identified the presence of a mass in the
right maxillary sinus with extension in the nasal cavity, causing the destruction of the medial
wall of the sinus.
Fig. 4. Computed tomography
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Fig. 5. Microscopic appearance, HEX 40
Emergency surgery was performed through a combined, endoscopic and open approach,
wide debridement to healthy tissue and mass ablation from the right maxillary sinus was
performed, which was sent for histopathological examination. The result was mucormycosis.
The patient underwent antibiotic, anti-inflammatory and antifungal treatment, but
unfortunately died a few days after surgery.
Second case
A 61-year-old patient, without a significant personal pathological history, presented to the
Colțea ENT Clinic sent by the dentist. The patient was undergoing a complex dental treatment
that requires a dental implant and the doctor requested a panoramic dental x-ray. This
revealed an opacified left maxillary sinus, for which the patient was sent to an ENT
consultation before continuing the dental treatment. At the clinical examination the only
changes were a deviation of the nasal septum on the left side and the hypertrophy of the
uncinate process on the left side seen endoscopically. The patient was sent to undergo a sinus
CT and return with the result. CT identified complete opacification of the left maxillary sinus
with dense areas which raised the suspicion of the presence of either dental material or fungi.
Fig. 6. Computed tomography
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Fig. 7. Intraoperative endoscopic appearance
It was decided to perform surgery by endoscopic approach. Under general anaesthesia and
endoscopic control, maxillary antrostomy was performed with lavage and drainage of the left
maxillary sinus. The material from the left maxillary sinus was collected and sent to the
laboratory. The result was Aspergillus Niger. Biopsies were also taken from the mucosa of the
left maxillary sinus, this is necessary to make sure that the fungi did not invade the mucosa, in
which case the surgical approach would be completely different. The result proved that the
sinus mucosa was healthy.
Fig. 8. Microscopic appearance HEX 40
Postoperatively under antibiotic and anti-inflammatory treatment, the patient's evolution

was good. At the stage control, the patient showed no signs of disease and was able to
continue dental treatment.
Conclusion
The first case of fungal rhinosinusitis was described in 1791 by Plaignaud at a 22-year-old
soldier. A “fungal tumour” was identified and treated with cauterization. A more accurate
description of the diagnosis of nasal and paranasal aspergillosis, a non-invasive form, was
made by Schubert in 1885. The first well-documented case of invasive aspergillosis was
described by Oppe in 1897. In this case, the infection of the sphenoid sinus extended to the
brain by erosion of the bone wall. Finally, the distinction between the two forms of fungal
rhinosinusitis was made by Hora in 1965.
It is fundamental to deepen the elements of positive and differential diagnosis for fungal
rhino-sinusal pathology. The two forms have a completely different approach, being
36
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imperative their rapid differentiation and emergency intervention in the case of the invasive
form.
REFERENCES
1. Invasive and non-invasive fungal rhinosinusitis – A review and update of evidence, Peter George
Deutsch, Joshua Whittaker and Shashi Prasad.
2. Otorhinolaryngology. Head Neck Surgery 2018, Current Understanding of Allergic Fungal
Rhinosinusitis. World J. Tyler M.A., Luong A.U.
3. Significance of serum antibodies against HSP 60 and HSP 70 for the diagnostic of infectious diseases:
Bleotu, Coralia; Chifiriuc, Mariana Carmen; Pircalabioru, Gratiela; et al., VIRULENCE Volume:
5Issue: 8 Pages: 828-831 Published: NOV-DEC 2014.
4. Fungal rhinosinusitis: A classification and schematization addressing current controversies. Arunaloke
Chakrabarti, David W. Denning, Berrylin J. Ferguson, Jens Ponikau, Walter Buzina, Hirohito Kita,
Bradley Marple, Naresh Panda, Stephan Vlaminck, Catherine Kauffmann-Lacroix, Ashim Das,
Paramjeet Singh, Saad J. Taj-Aldeen, A Serda Kantarcioglu, Kumud K. Handa, Ashok Gupta, M.
Thungabathra, Mandya R. Shivaprakash, Amanjit Bal, Annette Fothergill and Bishan D. Radotra.
F, Preda MA, Iovan VC, Stanca HT (corresponding author), Busuioc CJ, Oprişcan IC, Boruga O.”.
Rom J Morphol Embryol. 2018; 59(1): pp. 113-119; ISSN 1220-0522 (print) ISSN 2066-8279 (online).
https://doi.org/10.1155/2020/3526316.
https://doi.org/10.1007/s10103-019-02934-x.
https://doi.org/10.3892/etm.2019.7857.
doi: 10.3892/etm.2019.7635. Epub 2019 May 31.
2016, Vol. 1 (20), pp. 380-383.
37
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Salvage Surgery in Advanced Temporal Region Cancers
DINDELEGAN Maximilian George1,2, BULMACI Mara1,2,

UJVARY Laszlo Peter2, MANIU Alma Aurelia1,2
Emails: maximilian.dindelegan@gmail.com, marabulmaci@yahoo.com, ujvarypeter@outlook.com, almacjro@yahoo.com
Abstract
Introduction
Temporal region cancers comprise a multitude of tumours that may arise from different
parts of the temporal bone. Temporal bone squamous cell carcinoma (TBSCC) is a rare,
aggressive malignancy with a poor prognosis in advanced cases, but it is the most common
carcinoma of the temporal region. TBSCC can originate either at the level of the temporal
bone or in extra temporal regions such as the periauricular skin, auricular skin, and the parotid
gland. In patients with loco-regionally advanced tumours, salvage surgery followed by
radiotherapy represents a good option when choosing the treatment in selected cases.
Methods
This report presents a series of 4 out of 9 cases that were admitted to the E.N.T.
Department of the Emergency County Hospital of Cluj-Napoca presenting loco-regionally
advanced tumours (pT4) of the temporal region. The main complaints of the patients were
high-intensity pain or repeated bleeding from the tumour site. All patients underwent tumour
excision with or without subtotal petrosectomy, superficial or total parotidectomy, neck
dissection and radiotherapy in particular cases.
Results
All of the patients had a favourable short-term postoperative evolution with good healing
of the surgical wound which permitted adjuvant radiotherapy if it was needed. The survival
rate was 66% at 2 years after the surgical intervention.
Conclusion
Surgical management for patients with advanced temporal region cancer can be
challenging, but patients and surgeons shouldn’t lose their hope. A wide resection of the
tumour with safe surgical margins followed by reconstruction of the defect and postoperative
radiotherapy offers significant chance of treating the disease.
Keywords: temporal bone, squamous cell carcinoma, salvage surgery, radiotherapy, reconstructive surgery
Introduction
Temporal region cancers comprise a multitude of tumours that may arise from different
parts of this anatomical region. Histologically speaking, there is a wide range of cellular
origin, like adenocarcinomas, basocellular carcinomas, squamous cell carcinomas, sarcomas,
and others.
38
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Among all these, the squamous cell carcinoma is the most common histological type found
and described in literature. Temporal bone squamous cell carcinoma (TBSCC) is known to be
a rare malignancy yet very aggressive, accounting for 0.2% of all head and neck cancers. [1]
The aggressiveness consists mainly in locally advanced disease, due to the anatomical
configuration of the area. [2] TBSCC can originate either at the level of the temporal bone or
in extra temporal regions such as the periauricular skin, auricular skin, and the parotid gland.
At this point, there is no agreement regarding TNM staging for these tumours. The most
used classification system that has been used to define TBSCC is the Modified Pittsburgh
Staging System. [3]
Depending on the stage of the disease the treatment principles are based on a large
resection of the temporal bone, with or without superficial or total parotidectomy. For late-
stage cancer it may become very difficult to obtain clear resection margins, but surgery
remains the only solution for these patients. However careful programming of the treatment
plan must be made in advance, taking in consideration the significant morbidity of the radical
surgery and the post-operative quality of life. [1]
In this report we present 4 out of 9 cases that were managed in the ENT Department of the
Emergency County Hospital of Cluj-Napoca in the 2014-2018 period. All the patients
presented loco-regionally advanced tumours (T4) of the temporal region. The main
complaints of all the 9 patients were pain of high intensity and repeated bleeding from the
tumour site. All of the patients underwent local tumour excision with or without subtotal
petrosectomy, superficial or total parotidectomy, neck dissection and radiotherapy in
particular cases. They had a favourable short-term postoperative evolution with good healing
of the surgical wound with a survival rate of 66% at 2 years after the surgical intervention.
Case presentations
Case No. 1
The first case is that of an 85-year-old female patient which presented with a large left
preauricular exulcerated tumour. The tumour measured a diameter of approximately 6 cm.
The patient never had a medical check-up before presenting to our service. The main
complaint of the patient was the intense pain.
Fig. 1. 85-year-old patient with a large preauricular exulcerated tumour in the left ear. Preoperative image
The preoperative staging of the temporal region tumour was T4 according to the Modified
Pittsburgh Staging System. [1] Local excision of the tumour was performed combined with a
superficial parotidectomy, and selective neck dissection of levels II, III and Va on the left side
of the cervical region. To close the newly formed defect a local rotational flap was performed.
39
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The patient had a good postoperative healing of the surgical wound. The histology of the
tumour turned out to be squamous cell carcinoma. The patient underwent postoperative
radiotherapy and achieved a local control of the disease. She was lost from observation one
year after the surgical intervention.
Fig. 2. Local flap after the excision of the Fig. 3. Two-month postoperative appearance
temporal region tumour
Case No. 2
The second case is that of a 64-year-old female patient. She was also known with
hypertension, type II diabetes and dyslipidaemia. She observed a skin lump in the pretragal
area of the right ear 6 months before presenting to the ENT department. After 5 months the
lump exulcerated and started secreting pus from the exulceration. The tumour had a T4
staging according to the Modified Pittsburgh Staging System. [1]
Fig. 4. 64-year-old female patient with a right preauricular exulcerated lesion. Preoperative appearance
Local excision of the tumour was performed. The right auricle was excised along with the
tumour. Superficial parotidectomy was performed as well in this case together with right
selective neck dissection for levels II, III and Va. A local rotational flap was performed in
order to close the skin defect. The flap suffered postoperative necrosis with secondary healing
of the affected area. The histopathological result of the excised tumour was that of a basal cell
carcinoma. The patient underwent postoperative radiotherapy after the healing of the disease.
She was lost from observation after two and a half years.
40
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Fig. 5. Superficial parotidectomy. Fig. 6. One month postoperative

Intraoperative image appearance
Case No. 3
The third case is that of a 79-year-old male patient. He presented with a huge tumour of the
left auricle that extended in the retroauricular region that started to grow 2 years before
presenting to the ENT department. The patient also suffered from hypertension. Excision of
the tumour was performed with selective neck dissection for levels II, III and Va and
superficial parotidectomy. The defect was closed with primary suture of the wound margins.
Postoperative evolution was very good. The histology of the tumour was basal cell
carcinoma with squamous differentiation. This patient didn’t receive any postoperative
radiotherapy because of the diagnosis and the negative margins of the surgical resection
combined with the advanced age of the patient. The patient was followed up regularly for 4
years. He presented no recurrence of the disease for the period in which he showed for follow
up.
Fig. 7. 79-year-old male with left auricular Fig. 8. 3 months postoperative

tumour extending to the retroauricular area appearance
Case No. 4
In this case we have operated on a 40-year-old male that had 3 prior surgeries for a right
sided recurrent temporal basal cell carcinoma. Safe surgical margins couldn’t be achieved in
the previous surgical interventions. A large excision of the tumour with subtotal
petrosectomy, total parotidectomy and selective neck dissection for levels II, III and Va were
undergone during the surgery. To reconstruct the newly formed large defect a free
anterolateral musculocutaneous thigh flap (ALT flap) was performed with the help of the
Plastic Surgery department. The postoperative evolution was very good. The histological
result was basal cell carcinoma. In a second intervention the external auditory canal was
reformed with the help of a canaloplasty intervention. The patient underwent postoperative
radiotherapy. He obtained a 5-year survival and is still being followed up.
41
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Fig. 9. 40-year-old male patient. Fig. 10. ALT musculocutaneous free flap being
Intraoperative image placed to cover the defect
Fig. 11. 1 year postoperative Fig. 12. 1 year postoperative

appearance – frontal view appearance – lateral view
Discussions
We would like to emphasize that advanced temporal region cancers are often diagnosed in
advanced stages either because of late diagnosis, or because of late presentation of the patient
to the ENT surgeon. The cases that we chose to present show that even advanced stage
temporal cancer can be operated on with good postoperative outcomes if appropriate surgical
resection and postoperative radiotherapy (in selected cases) are attained. In cases with large
defects following resection, free flaps done together with the plastic surgery department
represent the best reconstructive option. Even if curative resection can’t be achieved, tumoral
debulking followed by radiotherapy greatly improves the patients’ quality of life.
In advanced cancers of the temporal bone, as the cases operated on in our hospital, studies
found a survival between 14% and 49% at 5 years. The survival rate differs vastly from the
100% 5-year survival rate that was found in cases of early diagnosis and treatment of these
tumours. [4, 5]
Regarding the treatment of the disease, surgical intervention is undergone first and in case
of loco-regionally advanced cases it should be followed by adjuvant radiotherapy. [6]
A lateral temporal bone resection is indicated for T1 and T2 stages of the disease, with an
extended temporal bone resection indicated for stages T3 and T4. [7] Considering the low 5-
year survival rate of the advanced disease group, surgery followed by radiotherapy is used to
increase the quality of life of the patients and not necessarily to obtain curing of the temporal
bone disease. In case of large defects that arise from the extensive resection, free flaps can be
42
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used to cover the newly formed defects. Anterolateral thigh flap, radial forearm and lateral
arm flaps are used by plastic surgeons in these cases for reconstruction. [8, 9] In the cases
operated on in our clinic we had cases that underwent free flap reconstructions, cases that
benefited from local rotational flaps and some that benefited from primary wound closure.
Considering the late diagnosis and massive extent of the disease we chose to reduce the
tumour size so patients could benefit from postoperative radiotherapy even if tumour free
resection margins couldn’t be achieved. Chemotherapy and radiotherapy without surgical
resection aren’t considered a viable treatment option in advanced temporal region cancers so
surgical resection must be performed at least as a debulking technique so that adjuvant
radiotherapy can be undertaken. [10]
Temporal bone squamous cell carcinoma usually involves lymph node level II/III and Va
and in a smaller percentage of cases level IV (<10% of cases). [11] Based on these results
found by Gidley et al., when managing TBSCC, a selective neck dissection that incorporates
those nodal levels should be undertaken. In case of carcinomatous infiltration of the lymph
nodes the prognosis is poor and neck dissection doesn’t improve patients’ survival. [11, 12,
13]
Parotid dissection should be undertaken intraoperatively. Early diagnosed tumours (T1,
T2) should benefit from a superficial parotidectomy, because intraparotid nodes represent the
first station for EAC lymphatic vessels. In case of an advanced disease (T3, T4) which also
has an affected facial nerve function because of the tumour extension, total parotidectomy
must be undertaken. [14]
Unfortunately, because of the plethora of important structures in the temporal region and
complicated anatomy, obtaining tumour free surgical resection margins is often impossible. In
cases where free surgical margins can’t be obtained, the recurrence of the disease is more
likely, and the future survival time of the patient is reduced. Using extemporaneous
histopathological examination intraoperatively can aid the surgeon in obtaining safe resection
margins. [13, 15, 16]
Conclusions
In cases of patients with advanced temporal region cancer, the surgical management can be
challenging. Even if the 5-year survival rate of advanced temporal cancers isn’t as good as
that of the low stage temporal bone cancers (T1 and T2), patients and surgeons alike shouldn’t
lose their hope. A wide resection of the tumour with free surgical margins followed by
reconstruction of the defects using either local or free flaps and postoperative radiotherapy
offer a significant chance of treating the disease.
REFERENCES
1. Lechner M, Sutton L, Murkin C, et al., Squamous cell cancer of the temporal bone: a review of the
literature. Eur Arch Oto-Rhino-Laryngology. 2020; 1:3. doi:10.1007/s00405-020-06281-4.
2. Morris LGT, Mehra S, Shah JP, Bilsky MH, Selesnick SH, Kraus DH. Predictors of survival and
recurrence after temporal bone resection for cancer. Head Neck. 2012; 34(9): pp. 1231-1239.
doi:10.1002/hed.21883.
3. Gaudet JE, Walvekar RR, Arriaga MA, et al., Applicability of the pittsburgh staging system for
advanced cutaneous malignancy of the temporal bone. Skull Base. 2010; 20(6): pp. 409-414.
doi:10.1055/s-0030-1253575.
4. Moffat DA, Wagstaff SA, Hardy DG. The Outcome of Radical Surgery and Postoperative Radiotherapy
for Squamous Carcinoma of the Temporal Bone. Laryngoscope. 2005; 115(2): pp. 341-347. doi:
10.1097/01.mlg.0000154744.71184.c7
5. Masterson L, Winder DM, Marker A, et al., Investigating the role of human papillomavirus in
squamous cell carcinoma of the temporal bone. Head Neck Oncol. 2013; 5(2): pp. 1-8.
43
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6. Piras G, Grinblat G, Albertini R, Sykopetrites V, Zhong SX, Lauda L, Sanna M. Management of

squamous cell carcinoma of the temporal bone: long-term results and factors influencing outcomes. Eur
Arch Otorhinolaryngol. 2020 Sep 26. doi: 10.1007/s00405-020-06378-w. Epub ahead of print.
7. Hirsch BE, Chang CYJ. Carcinoma of the temporal bone. In: Myers EN (ed). Operative otolaryngology
head and neck surgery. Philadelphia: WB Saunders; 1997, pp. 1434-58.
8. Herr MW, Lin DT. Microvascular free flaps in skull base reconstruction. Adv Otorhinolaryngol 2013;
74: pp. 81-91.
9. O’Connel DA, Teng MS, Mendez E, Futran ND. Microvascular free tissue transfers in the
reconstruction of scalp and lateral temporal bone defects. J Craniofac Surg 2011; 22: pp. 801-4.
10. Nakagawa T, Kumamoto Y, Natori Y, et al., Squamous cell carcinoma of the external auditory canal
and middle ear: an operation combined with preoperative chemo-radiotherapy and a free surgical
margin. Otol Neurotol 2006; 27: pp. 242-8.
11. Gidley PW, Roberts DB, Sturgis EM. Squamous cell carcinoma of the temporal bone. Laryngoscope
2010; 120: pp. 1144-51.
12. Moody SA, Hirsch BE, Myers EN. Squamous cell carcinoma of the external auditory canal: an
evaluation of a staging system. Am J Otol. 2000 Jul; 21(4): pp. 582-8.
13. Masterson L, Rouhani M, Donnelly NP, et al., Squamous carcinoma of the temporal bone: clinical
outcomes from radical surgery and postoperative radiotherapy. Otol Neurotol 2014; 35(3): pp. 501-8.
14. Watkinson JC, Clarke RW. Scott-Brown’s Otorhinolaryngology Head & Neck Surgery. 8 th ed. CRC
Press; 2019. Volume 2. Chapter 115, Squamous cell carcinoma of the temporal bone; p. 1430.
15. Bacciu A, Clemente IA, Piccirillo E, Ferrari S, Sanna M (2013) Guidelines for treating temporal bone
carcinoma based on long-term outcomes. Otol. Neurotol. 34: pp. 898-907.
16. Gillespie MB, Francis HW, Chee N, Eisele Dw. Squamous cell carcinoma of the temporal bone: a
radiographic-pathologic correlation. Arch Otolaryngol Head Neck Surg 2001; 127: pp. 803-7.
44
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Epidemiological, Clinical and Therapeutic Aspects

in Odontogenous Sinusitis
ENEA Alexandru-Gabriel1, MUNTEANU Simona-Gloria1,2,3,

PĂUN Oana-Alexandra4, ANTONIE Catrinel-Beatrice Simion1,3,
BEJENARU Paula-Luiza1,3, CONDEESCU-COJOCARIȚA Mihnea Florin1,3,
NIȚU Liliana1,3, BERTEȘTEANU Șerban Vifor Gabriel1,3,
NICOLAESCU Alexandru3,5, POPESCU Bogdan1,3, MITRAN Denisa Maria1,
OTHMAN Amer1, POPA Teodora1, MOȘOIU Anca1, OANCEA Alina Lavinia1,3,
RUJAN Simona Andreea1, TAHER Bianca Petra1, CÎRSTEA Anca Ionela1,
OAȘĂ Irina Doinița1, FLORESCU Elena1, DIACONU Teodora Elena1,
DIMCEA Alisa1, SIREȚEANU Luiza Maria1, NEDELCU Ruxandra Ioana1,
VETRICEAN Iulia1, TUDOSIE Mihai Dumitru1,
TEODORESCU-ARGHEZI Ertan1, ANDRONE Roxana1, MAGDAN Mădălin1,
MIHALCEA Cătălin Constantin1, PAVĂL Cristian Costel1, COSTIN R.2,
GRIGORE Raluca1,3
1 ENT Department –Colțea Clinical Hospital, Bucharest, (ROMANIA)
2 ENT Department – Dr. Carol Davila Central Military Emergency Universitary Hospital, Bucharest, (ROMANIA)
3 ENT Department – “Carol Davila” University of Medicine and Pharmacy, Bucharest, (ROMANIA)
4 ENT Department – Râmnicu Vâlcea Emergency Hospital (ROMANIA)
5 ENT Department – Prof. Dr. Dimitrie Gerota MI Hospital –Bucharest, (ROMANIA)
Email: alexandru.enea@rez.umfcd.ro
Abstract
Introduction
Odontogenic sinusitis is an inflammatory pathology of the paranasal sinuses, with dento-
alveolar starting point and is the main ethiology of unilateral maxillary sinusitis in people
aged 40-60 years.

To carry out this work, data were collected from the literature and selected clinical cases
hospitalized and treated in the ENT Department of Colțea Clinical Hospital, Bucharest.
Results
Although rhinosinusitis due to odontogenic cause is a common and intensely studied
pathology, the modes of clinical presentation are quite varied and sometimes misleading.
Whether it is a frank rhinosinusal symptomatology (rhinorrhoea, nasal obstruction) or a
purely accidental discovery following a dental consultation, odontogenic rhinosinusitis still
remains a curative challenge. The available therapeutic means are numerous and varied, of
choice being the medical treatment, with intranasal corticosteroids or, if the symptoms do not
remit, the surgical treatment is resorted to – functional endoscopic sinus surgery (FESS). In
our clinic, the most used surgical procedures are maxillary anthrostomy and, as the case may
be, anterior ethmoidectomy, with favourable long-term results and complete remission of
symptoms. Also, dental treatment is urgently needed, but the order of succession between
medical or surgical and dental treatment is still a controversy.
45
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Conclusions
Odontogenic rhinosinusitis, with a solid epidemiological component, varied clinical
picture, but also, with the availability of a multiple curative arsenal, is a pathology that
requires a multidisciplinary, prompt and individualized approach for favourable long-term
results.
Keywords: sinusitis, odontogenic, rhinosinusitis, rhinorrhoea, nasal obstruction
Introduction
The paranasal sinuses are air-filled cavities that communicate with the nasal cavities. All
but the sphenoid sinus is present at the birth and the maxillary sinus, although present at birth,
it remains very small until the second dentition, because the presence of the tooth germs in the
maxilla limits the extent of the sinuses. Due to the fact that the floor of the maxillary sinus is
closely related to the roots of the second premolar and first molar teeth, this creates a potential
route for the spread of the dentogenic infections and a tooth extraction may create a
communication between the oral cavity and maxillary sinus (oroantral fistula) [1].
Millions of people around the world are suffering from rhinosinusitis and, more than half
of them are going to office visits and about 10% to hospital visits each year. Odontogenic
sinusitis means the presence of rhinosinusal disease where clinical and paraclinical
(microbiologic or radiographic features) evidences could take into account the dental origin.
Mucoperiosteum or Schneiderian membrane iatrogenic injury are the most common causes
of the odontogenic sinusitis or, less common, periodontal or periapical disease. Local chronic
inflammation or disruption of the Schneiderian membrane are followed by the mucosal
inflammation and impaired mucociliary function, poorer mucus transport and, in the end,
blockage of the sinus ostia with bacterial infection and inflammation.
“A recent systematic review examining the ethiology of odontogenic sinusitis among 674
patients demonstrated that an iatrogenic ethiology accounted for 65.7% of cases, apical
periodontal pathology accounted for 25.1% of cases, and marginal periodontitis accounted for
8.3% [3-4]”.
The microbiology of such infections is different from nonodontogenic sinusitis, being
composed of polymicrobial mix of anaerobes (e.g., Peptostreptococus, Fusobacterium) [5-7].
The majority of cases are unilateral [4], that’s why odonogenic sinusitis should be
suspected in any patient with unilateral sinusitis with recent history of dental procedures,
especially upper teeth or long history of dental issues. Having a vast variety of clinical
presentation, starting from asymptomatic cases discovered on simple plain teeth radiography
by the dentist to the most common symptoms like postnasal drip, facial pain or pressure,
purulent anterior rhinorrhoea, foul smell and fatigue. Although the anterior rhinoscopy or
nasal endoscopy are one of the basic investigations of the rhinosinusal pathology, in the
odontogenic sinusitis the imaging modalities are the most sensitive (Fig. 1, 2).
46
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Fig. 1,2. Left odontogenic maxillary sinusitis
Taking into account the complexity and variety of the dental causes of this condition, a
close collaboration with the dentist is strongly recommended because, without fixing the
dental cause, the symptomatology would come back sooner or later.
Materials and Methods
To carry out this work, data were collected from the literature, selected and retrospected
review of 3 clinical cases hospitalized and treated in the ENT Department of Colțea Clinical
Hospital, Bucharest, during 2019-2021.
Patients’ demographic data were collected and the outcomes measured, including
successive nasal endoscopy or CT scans, operative details and follow up data.
Case One
For the first time, we’ll present the case of a 41 years old female patient, living in the urban
area, presented to ENT Clinic of Coltea Clinical Hospital, Bucharest, Romania, at the
indication of the dentist. She was in course of dental treatment for apical dental injury. During
the stomatological investigations, she had a plain teeth radiography, showing opacity of the
left maxillary sinus (Fig. 3) and the dentist recommended her an ENT physician visit.
Fig. 3. Left maxillary sinus opacity suggestive for left maxillary sinusitis
47
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At the clinical exam, the patient had scanty rhinorrhoea with no other signs or symptoms at
the nasal endoscopy and we decided to advise the patient to complete her dental treatment.
During the stomatological treatment we checked her up every two weeks with progressive
improvement of the condition until the complete remission of the symptoms, confirming the
importance of the ENT-dentist collaboration in this common pathology.
Case Two
This second case is about a 48 years old female patient, living in the rural area who
presented to ENT Clinic of Coltea Clinical Hospital, Bucharest, Romania, for bilateral
mucupurulent nasal discharge, nasal obstruction and hyposmia debuted by 3 months.
Clinical examination reveals mucupurulent secretions on both nasal cavities (Fig. 4), facial
pressure and pain and scanty secretions on the posterior pharyngeal wall. Also, this patient
had multiple dental caries, especially on the upper jaw teeth and she denied the dental
treatment for a long time ago. We recommended the patient intranasal corticoid spray for 3
months with follow up at every 3 weeks. The symptoms got better during treatment and, after
3 months, we hospitalized the patient in order to open the ostium of the maxillary sinuses by
functional endoscopic sinus surgery (FESS). At the admission, the patient had an almost
normal clinical exam, just few nasal secretions with normal biological parameters. The CT
scan showed bilateral maxillary sinus opacities, with radicular contact of the upper jaw teeth
(Fig. 5).
Fig. 4. Mucopurulent nasal secretions Fig. 5. bilateral maxillary sinus opacity
Under general anaesthesia and orotracheal intubation we practiced functional endoscopic

sinus surgery with opening of both the maxillary ostium and wash and drainage of the sinuses
(Fig. 6).
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Fig. 6. Maxillary antrostomy – FESS
After the surgery we checked the patient every two weeks with proper local healing and
very good functional results. Also, the patient went to the dentist and solved all her dental
problems and had a rigorous oral hygiene afterwards.
Case Three
This case is about a 27 years old male patient, living in the rural area, who came to the
Emergency Room for unilateral nasal obstruction, left mucopurulent rhinorrhoea, left
periorbital swelling and a frontal pseudotumoral mass (Fig. 6-7).
Fig. 6-7. Left periorbital swelling and frontal pseudotumoral mass
Clinical exam reveals that frontal pseudotumoral mass, with dimensions of about 4/4 cm,
soft, depressible, with fluctuating pattern and the left periorbital swelling with normal eye
movement and without nistagmus. Nasal endoscopy shows scanty mucopurulent nasal
secretion. The patient has poor oral hygiene with multiple dental caries and radicullar roots.
We hospitalized the patient, put him on local and systemic corticosteroid therapy and sent
him to have an emergency CT scan which found total fluid accumulation on the left maxillary
49
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sinus which breaks through the anterior and posterior ethmoidal cells and lisis of the orbital
wall determining the periorbital cellulitis; asimethrycal frontal sinuses with total parafluid
filling of the left frontal sinus and lisis of the anterior wall of the left frontal sinus and
extension of the fluid into the smooth tissue of the forehead (Fig. 8-9-10).
Fig. 8, 9, 10. CT scan of maxillo-ethmoidal sinusitis complicated with periorbital cellulitis
Under general anaesthesia and orotracheal intubation we performed functional endoscopic

sinus surgery with left maxillary antrostomy, left anterior ethmoidectomy, fronto-
ethmoidectomy with the DRAF II technique. (Fig. 11), incision and drainage of the left upper
eyelid abscess, and incision, drainage and washing of the left frontal sinus by anterior sinusal
wall perforation (Fig. 12).
Fig. 11. DRAF II fronto-ethmoidectomy Fig. 12. Frontal sinus incision and drainage
After the surgery we checked the patient every two weeks with proper local healing and
very good functional results. Also, the patient went to the dentist and solved all his dental
problems and had a rigorous oral hygiene afterwards.
Results
Although rhinosinusitis due to odontogenic cause is a common and intensely studied

pathology, the modes of clinical presentation are quite varied and sometimes misleading.
50
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Whether it is a frank rhinosinusal symptomatology (rhinorrhoea, nasal obstruction) or a

purely accidental discovery following a dental consultation, odontogenic rhinosinusitis still
remains a curative challenge. The available therapeutic means are numerous and varied, of
choice being the medical treatment, with intranasal corticosteroids or, if the symptoms do not
remit, the surgical treatment is resorted to - functional endoscopic sinus surgery (FESS). In
our clinic, the most used surgical procedures are maxillary anthrostomy and, as the case may
be, anterior ethmoidectomy, with favourable long-term results and complete remission of
symptoms. Also, dental treatment is urgently needed, but the order of succession between
medical or surgical and dental treatment is still a controversy.
Conclusions
Odontogenic rhinosinusitis, with a solid epidemiological component, varied clinical

picture, but also with the availability of a multiple curative arsenal, is a pathology that
requires a multidisciplinary, prompt and individualized approach for favourable long-term
results.
REFERENCES
1. Basic Otorhinolaryngology – A step by step learning guide 2nd ed – R. Probst et al.

2. Melen I, Lindahl L, Andreasson L, Rundcrantz H. Chronic maxillary sinusitis: Definition, diagnosis and
relation to dental infections and nasal polyposis. Acta otolaryngol (Stockh) 1986; 101: pp. 320-327.
3. Lechien JR, Filleul O, de Araujo PC, Hsieh JW, Chantrain G, Saussez S. Chronic maxillary
rhinosinusitis of dental origin: a systematic review of 674 patient cases. Int J Otolaryng 2014; pp. 1-9.
4. Pokorny A, Tataryn R. Clinical and radiologic findings in a case series of maxillary sinusitis of dental
origin. Int Forum Allergy Rhinol 2013; 3(12): pp. 973-9.
5. Brook I. Microbiology of acute sinusitis of odontogenic origin presenting with periorbital cellulitis in
children. Ann Otol Rhinol Laryngol 2007; 116(5): pp. 386-8.
6. Saibene AM, Vassena C, Pipolo C, et al., Odontogenic and rhinogenic chronic sinusitis: a modern
microbiological comparison. Int Forum Allergy Rhinol 2016; 6(1): pp. 41-5.
7. Arias‐Irimia O, Barona‐Dorado C, Santos‐Marino JA, Martinez‐Rodriguez N, Martinez‐Gonzalez JM.
Meta‐analysis of the ethiology of odontogenic maxillary sinusitis. Med Oral Patol Oral Cir Bucal 2010;
15: pp. 70-73.
8. Fabrication, characterization and bio-evaluation of novel antimicrobial composites based on
polycaprolactone, chitosan and essential oils Stoica, Petruta; Chifiriuc, Mariana Carmen; Rapa, Maria;
et al., Romanian biotechnological letters volume: 20 issue: 3 pages: 10521-10535 published: may-jun
2015.
https://doi.org/10.1155/2020/3526316.
https://doi.org/10.1007/s10103-019-02934-x.
https://doi.org/10.3892/etm.2019.7857.
Danciu C, Popescu I, Alexa E, Lazureanu V, Stanca HT. Exp Ther Med. 2019 Aug;18(2): pp. 932-942.
doi: 10.3892/etm.2019.7635. Epub 2019 May 31.
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15. Combined approach for large tumors of the nose and paranasal sinuses – case report, O. D. Palade,
Florentina Severin, Miorita Toader, M.D. Cobzeanu, Toader Corneliu. The Medical-Surgical Journal
2016, Vol. 1 (20), pp. 380-383.
17. Elective Neck Dissection in patients with stage T1-T2N0 carcinoma of the anterior tongue Mirea, D.;
Grigore, R.; Safta, D.; et al., Hippokratia Volume: 18 Issue: 2 Pages: 120-124 Published: 2014.
Bleotu, Coralia; Chifiriuc, Mariana Carmen; Pircalabioru, Gratiela; et al., VIRULENCE Volume: 5
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Flexible Endoscopic Surgery for Glottic Carcinoma in a Patient

with Temporomandibular Joint Ankylosis
GURĂU Petru1*, SENCU Eusebiu2, VETRICEAN Sergiu2

1 Department of Thoracic Surgery, “Timofei Moșneaga” Republican Clinical Hospital, Chișinău, (R. MOLDOVA)
2 Clinic of Otolaryngology, “N. Testemițanu” University of Medicine and Pharmacy, Chișinău, (R. MOLDOVA)
* Corresponding author: Petru Gurău
Email: pgurau@gmail.com
Abstract
Objectives
Assessment of non-traditional therapeutic approach to a patient with early glottic
carcinoma, who has contraindications to radiotherapy, open surgery and transoral endoscopic
surgery, that allows avoiding the risk of radiation therapy and general anaesthesia.
Methods
Flexible trans-nasal endoscopic Nd:YAG laser surgery under the local anaesthesia and
intravenous sedation was performed.
Results
Successful tumour ablation was obtained with 28 months follow-up.
Conclusions
In some cases, related to anatomic particularities (e.g., temporomandibular joint ankylosis,
limited head extension etc.) and major risk for general anaesthesia, trans-nasal flexible
endoscopy with laser vaporization under local anaesthesia is a reasonable alternative for
performing a minimally invasive intervention for early glottic carcinoma.
Keywords: glottic cancer, Nd:YAG laser, trans-nasal approach, endoscopic surgery, laser endoscopic cordectomy,
temporomandibular joint disorders
Introduction
Early glottic carcinoma can be treated with comparable local control rates by available
treatment modalities: radiotherapy, open partial laryngectomy and transoral laser
microsurgery.
Each of this method has contraindications and contains some risk and limitations for
patients in poor physical condition, due to potential side effects of radiation exposure or
general anaesthesia. Anatomical particularities can also preclude traditional endoscopic
surgery.
A rational therapeutic approach, that allows avoiding the risk of radiation therapy and
general anaesthesia, and, at the same time, allows to overcome limits, imposed by anatomical
particularities, is presented.
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This manuscript was approved by Ethical Committee of “Timofei Mosneaga” Republican

Clinical Hospital.
Patient is treated in the sitting upright position. After local topical anaesthesia with
Lidocaine spray 10%, flexible therapeutic bronchoscope (working channel – 2.8 mm) is
introduced trans-nasally to obtain good exposure of the glottis. For larynx anaesthesia,
Lidocaine 2% is instilled in the larynx by a catheter, introduced via working channel of the
bronchoscope. Flexible guide of the Nd:YAG laser (1064 nm) is introduced through the
working channel of the bronchoscope for tumour ablation, that is done in continuous
irradiation mode, the power being set up to 40W (Fig. 1).
Case report
A 75-year-old man, non-smoker, presented with 3-month history of moderate progressive
hoarseness.
Fiberlaryngoscopy demonstrated an exophytic flattened tuberous tumour with rose-
coloured surface, affecting the whole right vocal fold (Fig. 2). Biopsy of the tumour was
performed.
Histologic exam revealed squamous cell keratinizing carcinoma (G2). No evidence of
cervical lymphadenopathy was found either by palpation or ultrasound.
As an accompanying pathology, patient had temporomandibular joint ankylosis (Fig. 3),
limited head extension and an aggravated cardiologic status (arterial hypertension gr II, very
high added risk; ischemic and hypertensive cardiopathy with impaired diastolic function of
the left ventricle; mitral valve regurgitation gr II, tricuspid valve regurgitation gr II,
pulmonary valve regurgitation gr I; moderate pulmonary hypertension; long-standing
persistent atrial fibrillation; high thromboembolic risk (CHADS2 – 3 p); moderate
haemorrhagic risk (HAS-BLED – 1 p); CHF II NYHA).
Taking into consideration limited tumour extent (T1aN0M0), contraindication for
radiotherapy and transoral laser surgery, and major risk for general anaesthesia, flexible
endoscopic management of the tumour was proposed as the method of choice. Informed
consent was obtained from the patient.
Photo-vaporization of the tumour was performed with Nd:YAG laser (40W) under the
local anaesthesia with 2% Lidocaine hydrochloride and intravenous sedation with Propofol, in
sitting position, laser guide being introduced through the working channel of therapeutic
fiberbronchoscope, inserted transnasally to obtain good exposure of the lesion (Fig. 4).
2 days later the patient was discharged from the hospital.
Results and discussion
Follow-up flexible endoscopic exams in 2, 4, 7, 13 and 28 months after operation didn’t

reveal any evidence of recurrence of laryngeal tumour (Fig. 5). No evidence of cervical
lymphadenopathy was found.
The available treatment opportunities for early glottic carcinoma, having comparable
oncological outcomes, also have some limitations and contraindications.
Radiation therapy, being preferred by some authors as first line choice, is related to worse
organ preservation rate compared to surgery and contains the risk of some complications, that
could affect quality of life of the patient (xerostomia, local edema, hypothyroidism,
accelerated carotid artery narrowing, skin and salvary changes, limitation of neck movement,
chondronecrosis, risk of second malignancy in the area of radiation etc.) [1]. Open surgery is
related to increased morbidity, temporary tracheostomy, longer hospitalization time and
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higher costs [2]. Transoral microsurgery has some advantages over radiotherapy and open
surgery (lower morbidity, shorter treatment and hospitalization time, less damage to healthy
tissues compared to those of radiotherapy, superior functional results compared to those of
open surgery [3]. But transoral laser microsurgery has also some limitations: short neck, large
tongue base, poor exposure of the anterior commissure in some patients, reduced mouth
opening, retrognathism, impaired cervical mobility and associated risk of general anaesthesia
[4].
In accessible English literature we have found only one article dedicated to flexible
endoscopic laser surgery of early glottic carcinoma [5], and no references concerning flexible
endoscopic approach in treatment of glottic carcinoma in a patient with temporomandibular
joint ankylosis.
Flexible endoscopic laser surgery is a method, that allows complete eradication of tumour,
avoiding the risk related to radiation therapy and general anaesthesia. The impossibility of
histologic exam of the margins of resected specimen is a drawback of the technique, that can
be compensated partially by multiple biopsies from the margins and the bottom of the tissue
defect following photo-vaporization and close follow-up in short time intervals, that permits
early detection of recurrence.
Conclusions
The obtained results demonstrate, that in some cases, related to anatomic particularities
(e.g., temporomandibular joint ankylosis, limited head extension etc.) and major risk for
general anaesthesia, trans-nasal flexible endoscopy with laser vaporization under local
anaesthesia is a reasonable alternative for performing a minimally invasive intervention for
early glottic carcinoma.
Figures
Fig. 1. Transnasal approach for Nd:YAG laser ablation of glottic tumour
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Fig. 2. Exophytic flattened tuberous tumour with rose-coloured surface, affecting the whole right vocal fold
Fig. 3. Maximal mouth opening (temporomandibular joint ankylosis)
Fig. 4. Tissue defect, formed immediately after laser vaporization of the tumour
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Fig. 5. 13 months after operation: no evidence of tumour recurrence
REFERENCES
1. August M, Wang J, Plante D, et al., Complications associated with therapeutic neck radiation. J Oral
Maxillofac Surg. 1996; 54: pp. 1409-15.
2. Rubinstein M, Armstrong W. Transoral laser microsurgery for laryngeal cancer: A primer and review of
laser dosimetry. Lasers Med Sci. 2011; 26: pp. 113-24.
3. Gallo A, de Vincentiis M, Manciocco V, et al., CO2 laser cordectomy for early-stage glottic carcinoma:
a long-term follow-up of 156 cases. Laryngoscope 2002; 112: pp. 370-4.
4. Sjögren EV. Transoral laser microsurgery in early glottic lesions. Curr Otorhinolaryngol Rep. 2017; 5:
pp. 56-68.
5. Lai JP, Tao ZD, Xiao JY, et al., Microinvasive Nd:YAG laser therapy of early glottic carcinoma and its
effect on soluble interleukin-2 receptor, interleukin-2, and natural killer cells. Laryngoscope 2001; 111:
pp. 1585-8.
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Universal New-born Hearing Screening: The Experience

of Children’s Clinical Hospital for Children
IONESCU Diana1, GRIGORE Raluca2, BERTESTEANU Serban2,

BURUIANA Laura1, RUS Olimpia1, SOREANU Cristian1*,
HERA Maria Cristina1
1 Children’s Clinical Hospital “Victor Gomoiu”, ENT Clinic, Bucharest, (ROMANIA)
2 Coltea Clinical Hospital, ENT Clinic, Bucharest, UMF Carol Davila Bucharest, (ROMANIA)
* Corresponding author: Soreanu Cristian
Email: cristiansoreanu@gmail.com
Abstract
Background
Our Hospital is part of the National Program VI.1.5 “Prevention of hearing impairments
through neonatal screening” from 2019. This study aims to present a statistic obtained on the
group of children tested by auditory screening in the period July 2019-January 2020 in our
institution.
Methods
It is a retrospective study on 589 new-borns’ aged between 0 month and 6 months tested in
our clinic. Screening is organised with two levels: TOAE (transient otoacustic emissions)
used for the first level and automated auditory brainstem response for the second level. For
the second level test are included babies with risk factors for neurosensorial deafness and
children with “refer” results at the TOAE test.
Results
During the first level test, 17% (99) new-borns has at least one ear with pathological result
(“refer”) at the first test and after TOAE control only 6,5% (38) confirmed the “refer” result.
50,9% babies (306) had perinatal risk factors for neurosensorial deafness. We practiced
automated ABR to 314 babies. We identified in our clinic 20 new-borns with neurosensorial
hearing loss (3,3%).
Conclusion
The diagnosis of hearing loss made in the first year of life allows the effective
rehabilitation of the child. In this way the child manages to acquire the language, to integrate
in the community and to develop harmoniously from both auditory and psychoemotional
point of view.
Keywords: auditory screening, TOAE, screening ABR
Background
Our Hospital is part of the National Program VI.1.5 “Prevention of hearing impairments
through neonatal screening” from 2019. This study aims to present a statistic obtained on the
group of children tested by auditory screening in the period July 2019-January 2020 in our
institution.
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The history of the neonatal auditory screening begins in the 60s, when the audiological
community became aware that the incidence of deafness in new-borns is 1/1000 and that there
are non-invasive tests that can detect this pathology from birth. In the past decade, universal
new born hearing screening has been widely adopted throughout North America, Europe (1),
(2), (3), (4), (5), (6), (7), (8).
Worldwide the prevalence of moderate and severe bilateral hearing loss is 1-3 per 1000
live births in healthy new-borns population and 2-4 in 100 infants in an intensive care
population.
Hearing loss is one of the most frequent congenital anomalies.
Universal new-born hearing screening (UNHS) is a strategy that identify congenital
deafness and hearing loss. The objective is to make the diagnosis in the first year of life in
order to maximize auditory rehabilitation results and linguistic competence. Children
undiagnosed present with delays in speech development and psychological disorders that
impact their social life.
The ethiology includes genetic factors and environmental factors. 70% of the genetic
hearing loss cases are nonsyndromic and half of them are linked to the connexin gene. The
nongenetic causes can be prenatal causes (cytomegalovirus infection, TORCH infections),
perinatal causes (prematurity, low Apgar score, hypoxia, hyperbilirubinemia, ototoxic drugs
such as aminoglycosides, persistence in neonatal intensive care unit, mechanical ventilation,
prolonged oxygen supplementation), occasional and unknown (9), (10), (11), (12).
The risk factors for neurosensorial hearing loss, universally accepted, are: family history of
hearing loss, congenital infections, craniofacial anomalies, low birth weight (<1500g),
hyperbilirubinemia, ototoxic medications (aminoglycosides, loop diuretics), bacterial
meningitis, low Apgar scores (0-4 at one minute, or 0-6 at five minutes), mechanical
ventilation for at least 5 days, genetic syndromes.
There are two screening tests that are used to detect hearing loss: recording acoustic
otoemissions and screening ABR. How these tests are used can lead to different hearing
screening protocols:
• AABR only – can be used in NICU and in well-infant nursery,
• OAEs only – recommended for use in well-infant nursery,
• OAE followed by AABR when the OAE is not passed – OAE screening is completed
on both ears first, AABR is only done for those new-borns that do not pass the OAE
screen. If one or both ears do not pass the AABR, the infant is referred for outpatient
diagnostic testing,
• Both AABR and OAE – new-borns must pass both an OAE and an AABR screening.
The new-born who fails one or both screenings in one or both ears, is referred for
outpatient diagnostic testing. The most precise but also the most expensive protocol
(13), (14).
The child with hearing loss, with a late diagnosis, is much more difficult to rehabilitate.
The degree of disability may have an important emotional impact and may have
consequences on the quality of social life (15), (10), (16), (17).
Methods
It is a retrospective study on 589 new-borns aged between 0 month and 6 months tested in
our clinic. Screening is organised with two levels: TOAE (transient otoacustic emissions)
used for the first level and automated auditory brainstem response for the second level. For
the second level test are included babies with risk factors for neurosensorial deafness and
children with pathological (“refer”) results for at least one ear at the TOAE test. TOAE and
automated ABR are the most used techniques for the auditory screening. They are validated
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by the professional organizations. The TOAE test usually takes few minutes and can be done
without audiological expertise, that is why this test is used in the maternities. OAE has high
sensitivity (85-100%), and reasonable specificity (91-95%). The false positive cases are due
to external canal anomalies, and middle ear condition (fluid and mucus), as well as the
ambient noise. We used a SERA equipment (Interacoustics) and a Natus equipment.
Automated ABR is a direct measurement of the neural response to sound. It is less
susceptible to false positives than OAE. Other advantages are the fact that allows for
detection of neurologic involvement and that more of the auditory system is assessed
compared with OAE.
There is no universal protocol for auditory screening. The recommendation is that each
country should adopt its own protocol according to regional administrative possibilities. Our
national neonatal auditory screening protocol use the TOAE test. In our hospital, which is a
tertiary audiological centre, we use both TOAE and screening ABR in order to identify
pathological cases.
Results
During the first level test, 17% (99) new-borns were “refer” at the first test for at least one
ear and after TOAE control only 6,5% (38) confirmed the pathological result at least one ear,
more than half having risk factors. In some cases, was necessary to retest the baby because we
find a pathological tympanogram, suggesting serous otitis.
50,9% babies (276) had risk factors for neurosensorial deafness. We practiced automated
ABR to 314 babies (276 with risk factors and TOAE pass bilaterally, 30 with risk factors and
refer TOAE for one or two ears, 8 without risk factors and TOAE refer for one or two ears).
We identified finally in our clinic 20 new-borns with neurosensorial hearing loss (3,3%).
Of the total number of patients with screening tests with pathological TOAE results
(6.5%), more than half (18/38) were subsequently diagnosed with neurosensory hearing loss.
20 (20/38) patients had normal screening ABR.
Of all 20 patients with neurosensorial hearing loss 2 had a mild hearing loss, 2 had a
moderate hearing loss, 1 had a unilateral profound hearing loss and 2 had a severe hearing
loss.
All the rest (13) had a profound bilateral hearing loss. The final diagnosis was made using
ABR and ASSR. In this group (20 patients), 13 (65%) children had risk factors for deafness.
17 (17/20) had pathological results for both TOAE and automated ABR. 3 new-borns with
neurosensorial hearing loss had TOAE pass and pathological screening ABR, being diagnosed
with auditory neuropathy.
7 patients (7/38) who had TOAE refer at one ear at least, had normal (“pass”) results for
automated ABR at 35 dB. We supervise them, in order to not to miss a mild hearing loss.
In the group of babies that had risk factors for deafness, we had some particular cases of
genetic sindroms like: Down syndrome, Myhre syndrome, oculo-dental syndrome, Duchenne
dystrophy, Antley Bixler syndrome, Binder syndrome, Wolf Hirhhorn syndrome, SPATA
syndrome, mitochondrial depletion syndrome and a genetic syndrome with bilateral
anophthalmia which will be treated in a future paper on rare diseases.
Discussion
Our results highlight a significant rate of false positive results for TOAE. For that reason,
we usually retest the patient.
The use of tympanometry with a 1 Hz probe helps in the evaluation process, to select the
cases in which the presence of serous otitis is present, especially frequent in the cases of
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children diagnosed with genetic syndrome. In these cases, the registration of TOAE is
rescheduled until the resolution of the acute pathology.
The existence of cases with absent TOAE and normal results for automated ABR means
that the results were false positive or the fact that in some cases TOAE cannot be registered
even if there is a normal hearing. Another hypothesis can be that the patients may have a mild
deafness that cannot be identify with automated ABR at 35 dB, and the absence of TOAE is a
sign of an incipient cochlear pathology.
The incidence of hearing loss in our group (3,3%) is higher than in the study conducted by
Cianfrone et al., (18), this difference is probably due to the difference between the study
populations, our group being considerably smaller.
In the group of 20 babies with neurosensorial hearing loss, 17 had absent TOAE, meaning
that in the most cases, TOAE is the alarm signal for the diagnosis.
Also, we can affirm that 65% (13) of the group of 20 babies with neurosensorial hearing
loss had perinatal risk factors, which means that this type of ethiology is frequent and has an
important impact.
There are limitations of the screening protocol, more precisely, there is a risk for the cases
with mild hearing loss (below 30 dB) that is usually missed (because all the screening test are
“pass”) and also, progressive hearing loss in children without risk factors, examined only with
TOAE at birth, can be diagnosed later with delay. Also, in the case of auditory neuropathy,
children may initially have TOAE present, thus escaping the diagnosis of hearing loss.
Consequently, we established that in our protocol we should also use screening ABR in
children with risk factors for hearing loss, at least once during follow-up evaluations, even if
the TOAE result is “pass” bilaterally (13).
Conclusions
It is essential that national hearing screening programs work everywhere in order to

identify children at risk for hearing loss. Early verbal auditory rehabilitation of children,
offers them the chance to develop and integrate into society, increasing their quality of life.
Auditory screening is a procedure that has shown over time that false-positive rates,
indicating the proportion of normally hearing children who are referred for diagnostic testing,
are reported to be between 2% and 4% in most UNHS programs, with well-established
programs reporting rates of 0.5% to 1.0%. Comparatively, the false-positive rates for new-
born thyroid screening are approximately 2% (9), (19), (20).
It is necessary to reduce the high rate of lost-to-to-follow up infants by creating a dedicated
administrative system to remind the parents of their future appointments.
Using both TOAE and screening ABR we can provide an accurate screening for hearing
loss. This combination should be considered a standard protocol.
Abbreviations and Acronyms

TOAE-transient otoacustic emissions
ABR-auditory brainstem evoked response
ASSR-auditory steady state response
AABR-automated auditory brainstem response (screening ABR)
REFERENCES
1. Sloot F, Hoeve HL, de Kroon M, Goedegebure A, Carlton J, Griffiths HJ, et al., (2015). Inventory of
current EU paediatric vision and hearing screening programmes. J Med Screen. 22(55), p. 64.
2. Durieux-Smith A, Fitzpatrick E, Whittingham J. (2008). Universal new-born hearing screening: a
question of evidence. Int J Audiol. 47(1), p. 10.
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3. Vos B, Senterre C, Lagasse R, Tognola G, Levêque A. (2016). Organisation of new-born hearing

screening programmes in the European Union: widely implemented, differently performed. Eur J Public
Health. 26(3), pp. 505-10.
4. Wood SA, Sutton GJ, Davis AC. (2015) Performance and characteristics of the New-born Hearing
Screening Programme in England: The first seven years. Int J Audiol. 54(6), pp. 353-358.
5. Vos B, Senterre C, Lagasse R; SurdiScreen Group, Levêque A. (2015) New-born hearing screening
programme in Belgium: a consensus recommendation on risk factors. BMC Pediatr. 15, p. 160.
6. Berrettini S, Ghirri P, Lazzerini F, Lenzi G, Forli F. (2017). New-born hearing screening protocol in
Tuscany region. Ital J Pediatr. 43(1), p. 82.
7. Turchetta R, Conti G, Marsella P, et al., (2018). Universal new-born hearing screening in the Lazio
region, Italy. Ital J Pediatr. 44(1), p. 104.
8. Choo D, Meinzen-Derr J. Universal new-born hearing screening in 2010. (2010) Curr Opin Otolaryngol
Head Neck Surg. 18(5), pp. 399-404.
9. Patel H, Feldman M. Universal new-born hearing screening. (2011). Paediatr Child Health. 16(5), pp.
301-310.
10. Erenberg A, Lemons J, Sia C, Trunkel D, Ziring P. (1999). New-born and infant hearing loss: detection
and intervention. American Academy of Paediatrics. Task force on new-born and infant hearing, 1998-
1999. Pediatrics. 103, p. 527.
11. Yoon PJ, Price M, Gallagher K, Fleisher BE, Messner AH. (2003). The need for long-term audiologic
follow-up of neonatal intensive care unit (NICU) graduates. Int J Pediatr Otorhinolaryngol 67, pp. 353-
7.
12. Hille ET, van Straaten HI, Verkerk PH. (2007). Dutch NICU Neonatal Hearing Screening Working
Group. Prevalence and independent risk factors for hearing loss in NICU infants. Acta Paediatr 96, pp.
1155-8.
13. Wroblewska-Seniuk, K., Dabrowski, P., Szyfter, W. et al., (2017). Universal new-born hearing
screening: methods and results, obstacles, and benefits. Pediatr Res 81, pp. 415-422.
14. Kaye CI, Accurso F, La Franchi S, Lane PA, Hope N, Sonya P, et al., (2006). New-born screening fact
sheets. Paediatrics. 118, pp. e934-e963.
15. Mason A, Mason M. (2007). Psychologic impact of deafness on the child and adolescent. Prim Care.
34, pp. 407-26.
16. Papacharalampous GX, Nikolopoulos TP, Davilis DI, Xenellis IE, Korres SG. (2011). Universal new-
born hearing screening, a revolutionary diagnosis of deafness: real benefits and limitations. Eur Arch
Otorhinolaryngol 268, pp. 1399-406.
17. Pimperton H, Kennedy CR. (2012). The impact of early identification of permanent childhood hearing
impairment on speech and language outcomes. Arch Dis Child 97, pp. 648-53.
18. Cianfrone F, Mammarella F, Ralli M, Evetovic V, Pianura CM, Bellocchi G. (2018) Universal new-
born hearing screening using A-TEOAE and A-ABR: The experience of a large public hospital. J
Neonatal Perinatal Med. 11(1), pp. 87-92.
19. Nelson HD, Bougatsos C, Nygren P. (2008). Universal new-born hearing screening: Systematic review
to update the 2001 US Preventive Services Task Force Recommendation. Paediatrics.
20. Durieux-Smith A, Fitzpatrick E, Whittingham J. (2008). Universal new-born hearing screening: a
question of evidence. Int J Audiol. 47, pp. 1-10.
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Borderline Frontal and Ethmoid Osteoma – Full Endoscopic

Approach
LOSTUN Alexandra1,2, LOSTUN Gabriel3*, ȘTEFAN C.1,

ȘTEFĂNESCU Dragoș Cristian5,6, HAINĂROȘIE Răzvan5,7
1 Forensic Medicine Department Brașov (ROMANIA)
2 Faculty of Medicine, Transylvania University Brașov (ROMANIA)
3 Emergency Military Hospital Queen Mary Brașov (ROMANIA)
4 Children’s Hospital Brașov (ROMANIA)
5 Carol Davila Medicine and Pharmacy University Bucuarești (ROMANIA)
6 Gen. Dr. Aviator Victor Atanasiu National Institute of Aeronautical and Space Medicine București (ROMANIA)
7 I.F.A.C.F. Prof Dr Dorin Hociotă București (ROMANIA)
* Corresponding author: Lostun Gabriel
Email: gabriellostun@gmail.com
Abstract
Introduction
The tumoral pathology of the paranasal sinuses has a wide variation as it regards the
histology types. An important chapter is the one of bone tumours developed from the walls of
paranasal sinuses.
Material and method

The authors will present the particular case of an osteoma locate at the border between
frontal and ethmoid sinus with a double insertion – on the middle turbinate which had a Keros
3 insertion itself on the cranial base and on the anterior wall of the frontal sinus.
Results
The case was a challenge from the point of view of insertion of the tumour but was solved
exclusively in an endoscopic manner. The patient was discharged the same day with a light
left nasal and meatal contention.
Conclusions
The bone tumours of the nasal sinuses are generally benign and do not always require
surgery. However, from the point of view of small working spaces and insertion areas they
can be a challenge for the ENT surgeon and one should keep in mind that it can never
sacrifice the results of the surgery for the surgeon’s pride.
Keywords: osteoma, frontal sinus, ethmoid sinus, middle turbinate, Keros
Introduction
One of the most frequent pathology of the paranasal sinuses is the chronic rhinosinusitis.
This condition can exist on itself or it can accompany other pathologies such as tumours.
Taking these into consideration any specialist examining an imagistic study should take
great care of the collateral signs of a sinusitis in order to achieve a correct diagnostic.
The tumours of the paranasal sinuses are most usually located in the maxillary sinus
(carcinoma, adenocarcinoma etc.), the ethmoid sinus (carcinomas, osteomas, inverted
papillomas) and more rarely in the sphenoid or frontal sinuses. More often in the frontal or
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sphenoid sinus we can find tumours of the surrounding anatomic structures that break their
path in these cavities. [1, 2, 3, 4]
Material and method
In this article the authors chose to present the case of a male patient in the mid forty’s that
accused chronic sinusal pain on the left side of the face, mainly in the ethmoid and frontal
sinus region. At first this might not have been considered as a starting point for a sinusitis
discussion and it looked more like migraine or neuralgia.
The imagistic examination by CT scan and MRI in the previous 9 months showed no signs
of sinusitis, not even a thickening of the sinus mucosa. The main findings were a large concha
bulosa and an osteoma of the border teritory between frontal and ethmoid sinus. The drainage
path was small but maintained for the frontal sinus but the insertion of the osteoma was on the
posterior table of the frontal sinus and on the insertion of the middle turbinate. As a
supplementary difficulty factor for this case there was a Keros III positioning of the cranial
base and the middle turbinate insertion was on the cranial base. As it regards the concha
bulosa it seemed to have a compression effect on the septum and ostiomeatal complex but
with no purulent content. Pictures 1 to 5 underneath the text show the anatomic situation.
Picture 1. View of concha bulosa
Picture 2. The osteoma in the frontal recess
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Picture 3. The insertion of the osteoma
Picture 4. Cranial base insertion of the osteoma
Picture 5. Sagittal view of the insertion
The condition found on the imagistic examinations related perfectly with the clinical signs
described by the patient. We therefore proposed a surgical approach and informed the patient
of the CSF leak risk and asked for consent for a probably needed external approach.
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Results
Under general anaesthesia with oro-tracheal intubation we started the procedure by

endoscopic approach. There was no problem dealing with the concha bulosa and as we
reached the frontal recess, we found ourselved in front of a usual problem at this point –
identification of the bony tumour as all structures in this area are covered by mucosa and no
purulent secretion pathway was there to follow. However, after a careful dissection of the
frontal recess we managed to identify the pathological element and with great care we
mobilized it using mainly a J curette and sinus seeker. As the opening was large after dealing
with concha bulosa we did not need more than a 0- and 30-degree endoscope. Bleeding was
moderate as the patient was considered healthy not considering the ENT disease. As the
dissection of the structures was extensive, we applied minimum tamponament in order not to
put unnecessary pressure on the adiacent anatomic landmarks. At dissection we found another
point of insertion at the base of the middle turbinate (Picture 6). The excision piece was quite
large (approx 1 cm in diameter) but we were able to fully excise it by endoscopic approach.
Another difficult time was taking it out from the frontal recess were it continuously slipped
as it had a round shape. The patient was discharged HTE next day after surgery, after
elimination of the nasal sponges.
At 7 and 30 days postoperative follow up the facial pain in the left ethmoid and frontal
sinusal points disappeared. The patient had no complications.
The pathology response to the tissue sent for analysis was osteoma without any
abnormalities, fully excised.
Picture 6. Intraoperatory endoscopic view of the osteoma
Conclusions
We consider the case presented above one of high difficulty. The main reason to consider it
like this is the positioning of the tumour – at the border between the frontal and ethmoid
sinus.
The other difficulty factor was the insertion of the osteoma on the middle turbinate and
posterior table of the frontal sinus combined with a Keros III cranial base situation.
The endoscopic approach was possible most probably because the insertion lines were not
very thick and permitted a blunt dissection. If this was not possible, we would have applied an
external technique in order not to use a burr or more force.
As the patient only complained of headache the correct diagnostic and surgical approach
led to complete resolution of the symptoms.
Every patient in such situation should be carefully monitorised in the first 24 hours after
surgery as orbital or cranial complications may appear.
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Knowing the regional anatomy combined with good imagistic investigations gives the
doctor safety in choosing the surgical path and at the same time safety of the results obtained
for the patient.
Discussions
This kind of cases can be very tricky for the ENT specialist in the first row. The challenge
resides firstly in having a correct diagnostic.
Concha bullosa is a well-known pathology that leads to headache. The osteoma however,
especially as in this case had no accompanying sinusitis rised some question marks.
The ENT specialist should always take a correct decision in order to achieve the best state
of health for his patient, be well prepared, offer alternative techniques and never push the
resolvation on a certain pathway only guided by the typical surgical self-esteem.[5]
One should always keep in mind that even if the external approach techniques for
paranasal sinuses are considered obsolete by ones the safety of not having cranial or orbital
complications always prevails in front of hypoesthesya of a territory or a scar on the face of
the patient.
REFERENCES
1. Kennedy DW, Keogh B, Senior B, Lanza DC (1996) Endoscopic approach to tumours of the anterior
skull base and orbit. Otolaryngol Head Neck Surg 7: pp. 257-263.
2. Messerklinger W (1978) Endoscopy of the nose. Urban and Schwartzenberg, Baltimore
3. Otorhinolaryngology, Head and Neck Surgery M. Anniko, M. Bernal-Sprekelsen, V. Bonkowsky, P.
Bradley, S. Iurato ISBN 978-3-540-42940-1.
4. Cummings otolaryngology – head and neck surgery fifth edition isbn: 978-0-323-05283-2 ie isbn: 978-
0-8089-2434-0.
5. Frontoethmoid Osteoma Operated by Combined Approach: A Case Report Vasant Gangadhar Pawar,
Manu S Babu, Suresh Kumar Tarachand Jain, Dharmendra K Rai, Supriya G Gaware Indian J
Otolaryngol Head Neck Surg 2019 Nov; 71(Suppl 3): pp. 2148-2150 doi: 10.1007/s12070-019-01670-
6. Epub 2019 May 13.
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Nasal Wing Foreign Body. Case Report
MAGDAN M.1, BERTEȘTEANU Ș.V.G.1,2, GRIGORE Raluca1,2,

NIȚU Liliana1,2, POPESCU B.1,2, OANCEA Alina1,2, IONESCU Diana1,5,
MUNTEANU Gloria Simona1,2,3, CONDEESCU-COJOCĂRIȚA M.1,2,
NICOLAESCU A.1,2,4, CÎRSTEA Anca Ionela1,2, OTHMAN A.1, POPA Teodora1,
DIMCEA Alisa1, NEDELCU Ruxandra Ioana1, DIACONU Teodora Elena1,
TAHER Bianca Petra1, RUJAN Simona Andreea1, SIREȚEANU Luiza Maria1,
OAȘĂ Irina1, MITRAN Denisa1, FLORESCU Elena1, ANDRONE Roxana1,
VETRICEAN Iulia1, MIHALCEA C.C.1, TUDOSIE M.D.1, PAVĂL C.C.1,
COSTIN R.3, ENEA A.G.1
1 ENT Clinic – Colțea Clinical Hospital, Bucharest (ROMANIA)
2 “Carol Davila” Medicine and Pharmacy University, Bucharest (ROMANIA)
3 “Carol Davila” Central Military Universitary Hospital Bucharest (ROMANIA)
4 “Prof. Dr. Dimitrie Gerota” IAM Hospital, Bucharest (ROMANIA)
5 “Dr. Victor Gomoiu” Children Clinical Hospital, Bucharest (ROMANIA)
Email: madalin.magdan@gmail.com
Abstract
Introduction
In ENT, the most common foreign bodies are unanimated, usually found in the upper
airways or in the external auditory canal. Less frequently we find animated foreign bodies and
those found after explosions, gunshots or trauma. In order to have a right diagnosis, the
clinical and imaging techniques must be performed thoroughly. The Computed Tomography
became the gold-standard when it comes to precisely diagnosing the post-traumatic foreign
bodies [1], [2], [3].
Methods
This paper presents the management of a 61 years old male patient, admitted to Coltea
ENT Clinic in order to have a right nasal wing metal foreign body extracted. The foreign
body was found during a cerebral MRI scan. The procedure was stopped and a Computed
Tomography was performed instead, confirming the presence of the metal foreign body.
Results
After analysing all the information, the trans-nasal surgical intervention was performed
under general anaesthesia, and the metal foreign body was removed.
Conclusions
This case’s unicity is represented by an important anamnestic detail offered by the patient.
He remembered having a minor nose bleeding while he was cutting a metal object using an
angle grinder, almost six years ago. This detail, associated with the lack of an externa entry
scar, suggested that the metal foreign body penetrated his right nasal wing, through his right
nasal orifice. The speed and the incandescent nature of the foreign body resulted in minor
bleeding and the lack of pain and infection afterwards.
Keywords: metal foreign body, scar, high velocity
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Introduction
In E.N.T., the most common foreign bodies are unanimated, usually found in the upper
bodies [1], [2], [3].
Methods
A 61 years old male patient, was admitted in our clinic with frontal and occipital headache
and a foreign body in the right nasal wing. He stated that the headache first appeared 6
months ago and his neurologist recommended him to undertake an MRI scan. When the
investigation began, the patient had an unusual hot sensation in the right half of the nose and
the technicians stopped the MRI scan due to a ferrous metal in the patient’s body. A later CT
scan revealed indeed the presence of a small metal object in the patient’s right nasal wing.
When the diagnosis was set, the patient was sent to our clinic in order to surgically remove
the foreign metal body.
The clinical examination revealed a 178 cm tall and 90 kg male patient, in a good mental
and physical state.
The E.N.T. examination was not able to identify a foreign body or any kind of scar at the
incriminated area. Only a thorough palpation revelled a small induration in the tegument of
the right nasal wing.
The blood tests did not show any evidence of an inflammatory response or any other kind
of modification.
The pulmonary Rx scan revealed some minor interstitial modifications in both lungs and a
normally sized hearth.
The CT scan revealed indeed a hyper dense metal object in the right nasal wing, which
measured approximatively 5/7,4 mm (Figure 1).
The positive diagnosis was indeed the presence of a metal foreign body in the right nasal
wing of the patient. The most valuable diagnostic tool was the CT scan, because neither the
patient’s anamnesis nor the clinical examination was clear in the matter.
The therapeutical approach was the surgical removal of the foreign body, under general
anaesthesia. Examining the CT indicated area using the endoscope’s light source was useful,
because we were able to pinpoint the exact location of the foreign body, in the absence of a
clinically observable mark (Figure 2).
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Fig. 1. The metal foreign object in the right nasal wing of the patient
Fig. 2. Trans-illuminating the right nasal wing and localizing the foreign body
Afterwards we used xiline and adrenaline in a local injection in order to prevent excessive
bleeding, the endonasal incision was then performed and the foreign body located (Fig. 3).
Fig. 3. After incising the mucosa of the nose, the foreign body was finally exposed
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The foreign body was then removed (Fig. 4) and after stopping the minor bleeding we
sutured the small incision and applied an anterior nasal packing which was removed after 24
hours after the surgery.
Fig. 4. The small metal object compared to a 10 mL syringe
The particularity of this case was the time passed from the traumatic event until the foreign
body was removed. After the surgical intervention the patient remembered that almost 6 years
ago, he had a minor nasal haemorrhage while working with an angle grinder in his backyard.
We then presumed that a small incandescent metal fragment pierced his nasal wing from
below. That explained the absence of pain and a local infection and also the lack of an entry
mark on his tegument.
Conclusions
In E.N.T., the most common foreign bodies are unanimated, usually found in the upper
bodies [1], [2], [3].
The entry mark was not identified in this particular case, so we presumed that it pierced his
nasal wing from below. The metal foreign bodies generated by grinding metal objects are
usually high velocity and incandescent, those characteristics might explain the absence of an
infectious response at the penetration site.
This patient’s case was a successful one because the foreign body did not affect an
important anatomical or functional site, but we must not forget that in our speciality, the
foreign bodies may pose life-threatening challenges for the patient.
REFERENCES
1. Guthrie D. Foreign bodies in the nose. J Laryngol Otol 1956; 41: pp. 454-7.
2. Ștefan Gârbea, Ionel Moga: Rinologie-Patologia nasului și a sinusurilor paranazale 1985, pp. 303-305.
3. Haghnegahdar A, Shakibafard A, Khosravifard N. Comparison between Computed Tomography and
Ultrasonography in Detecting Foreign Bodies Regarding Their Composition and Depth: An In Vitro
Study. J Dent (Shiraz). 2016; 17(3): pp. 177-184.
polycaprolactone, chitosan and essential oils: Stoica, Petruta; Chifiriuc, Mariana Carmen; Rapa, Maria;
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et al., ROMANIAN BIOTECHNOLOGICAL LETTERS Volume: 20 Issue: 3 Pages: 10521-10535

Published: MAY-JUN 2015.
5. Elective Neck Dissection in patients with stage T1-T2N0 carcinoma of the anterior tongueBy: Mirea,
D.; Grigore, R.; Safta, D.; et al., HIPPOKRATIA Volume: 18 Issue: 2 Pages: 120-124 Published: 2014.
https://doi.org/10.1155/2020/3526316.
https://doi.org/10.1007/s10103-019-02934-x.
https://doi.org/10.3892/etm.2019.7857.
doi: 10.3892/etm.2019.7635. Epub 2019 May 31.
2016, Vol. 1 (20), pp. 380-383.
14. Significance of serum antibodies against HSP 60 and HSP 70 for the diagnostic of infectious diseases;
By: Bleotu, Coralia; Chifiriuc, Mariana Carmen; Pircalabioru, Gratiela; et al., VIRULENCE Volume: 5
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Functional Results of Tympanoplasty With Partial Mastoid

Obliteration Due to Cholesteatoma. Prognostic Factors
MANIU Alma Aurelia1,2, BULMACI Mara1,2,

DINDELEGAN Maximilian George1,2, TĂNASE Mihai Ionuț1,2,
BLEBEA Cristina Maria2, NECULA Violeta1,2
Emails: almacjro@yahoo.com, marabulmaci@yahoo.com, maximilian.dindelegan@gmail.com, dr.mihaitanase@gmail.com,
cristina_blebea@yahoo.com, neculav@yahoo.com
Abstract
Objective
To assess the factors affecting hearing in patients who were operated on due to chronic
otitis media with cholesteatoma and underwent tympanoplasty with partial mastoid
obliteration.
Methods
A retrospective clinical study of 75 consecutive patients undergoing procedures for chronic
suppurative otitis media with cholesteatoma has been carried out. All surgical interventions
involved partial mastoid obliteration and restoration of the middle ear space by use of
cartilage reconstruction of the tympanic membrane. Ossicular reconstruction was achieved
with either a partial (PORP) or total titanium Kurz ossicular replacement prosthesis (TORP).
Success was defined as an air-bone gap (ABG) <20 db. Cholesteatoma locations, the type
of tympanic membrane perforations, intraoperative ossicular status, granulations in the middle
ear were evaluated. All patients had minimum follow-up period of 48 moths.
Results
No cavity problem was seen with achievement of an air-bone gap less than 20 dB in 70%
of PORP cases and 45% of TORP cases. Revision procedures for functional failure were
carried out in 23 patients.
Conclusions
Our results suggest that tympanoplasty with titanium partial or total ossicular replacement
prosthesis reconstruction offers a stable improvement of the ABG. The tensa type
cholesteatoma, missing malleus, and the presence of granulation tissue in the middle ear were
unfavourable prognostic factors.
Keywords: cholesteatoma, mastoid obliteration, tympanoplasty, functional results
Introduction
The goals of surgery for chronic otitis media with cholesteatoma are to eliminate infection
and to create a safe and dry ear while preserving hearing and providing adequate
reconstruction. [1] One common and well-established technique used for this purpose is the
canal wall down (CWD) mastoidectomy and tympanoplasty. [2] After cleaning the
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cholesteatoma, partial ossicular replacement prosthesis (PORP) or total ossicular replacement

prosthesis (TORP) can be applied. [3] There are numerous materials described in the setting
of ossiculoplasty. As an ossicular prosthesis, titanium has an optimal mass and stiffness to aid
in acoustic transmission, providing low acoustic impedance with minimal dampening of
sound. In this series, only patients with advanced cholesteatoma undergoing CWD
mastoidectomy together with ossicular reconstruction with a titanium prosthesis, were
studied, in order to identify factors associated with hearing outcomes.
Methods
Initially, a total of 110 patients who underwent surgical intervention for cholesteatoma
were included, but after the exclusion of those with limited disease, congenital cholesteatoma,
patients with reintervention and those who were lost from observation, a total of 75 patients
remained. A retrospective clinical study of 75 consecutive patients who had undergone
procedures for chronic suppurative otitis media with cholesteatoma has been carried out. All
surgical interventions involved partial mastoid obliteration, restoration of the middle ear
space, and reconstruction of the tympanic membrane with concha cartilage graft. [4]
Ossicular reconstruction was achieved with either PORP or TORP. Success was defined as
an ABG <20 dB. Cholesteatoma localization, the type of tympanic membrane perforation,
intraoperative ossicular status, granulations in the middle ear were evaluated. All
classifications and staging were made according to the EAONO/JOS Joint Consensus
Statements on the Definitions, Classification and Staging of Middle Ear Cholesteatoma. [5]
Audiograms were made by trained staff according to the ISO-389 (1975) standard.
Audiometric evaluation contained preoperative and postoperative ABG, AC, and BC
thresholds. All patients had a minimum follow-up period of 48 months. The results of
procedure were evaluated based on the guidelines of the Committee on Hearing and
Equilibrium of the Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). [6]
Qualitative variables were summarized using percentages and associated 95% confidence
intervals (95%CI).(7) Quantitative variables were summarized using mean and standard
deviation (mean ± standard deviation) whenever data proved to be normally distributed. The
Student’s T-test was used for the statistical comparison for the preoperative and postoperative
hearing outcomes.
Results
Air-bone (AB) – gain have been calculated in audiometric terms, closure of the
preoperative ABG, and improvement of the air conduction threshold (AC-PTA). These
parameters were analysed depending on cholesteatoma localization, the type of prosthesis, the
localization of the tympanic membrane perforation, the status of middle ear cavity and the
status of the ossicular chain. The sex and the age of the patients did not significantly influence
any of the parameters.
The AC-PTA improved significantly in all cholesteatoma locations; the biggest
improvement was for to location type cholesteatoma meaning attic-mastoid cholesteatoma.
The average postoperative AC-PTA and AC-PTA gain values for each type are shown in
Table 1.
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Table 1. AC-PTA status depending on the cholesteatoma localization
Table 2. ABG status depending on the cholesteatoma localization
Preoperatively there were no significant differences between categories, AC-PTA

postoperatively for the TORP group was significantly different from PORP group. AC-PTA
gain was significantly lower for TORP than PORP. (Table 3, Figure 1)
Table 3. AC-PTA status depending on the type of prosthesis
Fig. 1. AC-PTA status depending on the type Fig. 2. ABG status depending on the localization
of prosthesis of the tympanic membrane perforation
Preoperatively there were no significant differences between categories, AB gain

postoperatively for the Schrapnell membrane perforation group was significantly different
from the postero-superior and pars tensa perforation group. AB gain was significantly lower
for Schrapnell perforation than postero-superior perforation and pars tensa perforation. (Table
4, Figure 2)
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Table 4. ABG status depending on the localization of the tympanic membrane perforation
Preoperatively there were no significant differences between categories. AC-PTA

postoperatively was not significantly different between categories. AC-PTA gain was
significantly lower for the dry cavity than the cavity with granulations. (Table 5, Figure 3)
Table 5. AC-PTA status depending on the status of the tympanic cavity

AC-PTA preoperative AC-PTA postoperative AC-PTA gain
wet (n=13) 50.29±16.91 32.88±10.82 17.40±10.77
granulations (n=26) 49.76±13.31 36.92±9.46 12.84±11.61c
dry (n=36) 50.73±11.81 30.31±10.98 20.42±6.40
p 0.97 0.08 0.03
Fig. 3. AC-PTA status depending on the status of the tympanic cavity
Preoperatively there was no significant difference between the group with or the group
without stapes. Postoperatively, AC-PTA was significantly different between the two
categories. AC-PTA gain was significantly lower for those with stapes than for those without.
Preoperatively there was no significant difference between the two categories. (Table 6, Table
7)
Table 6. AC-PTA status depending on the ossicular chain status

PTA-AC preoperative PTA-AC postoperative AC-PTA gain
Without stapes (n=31) 52.06±11.68 38.55±13.49 13.51±10.76
With stapes (n=44) 49.09±12.45 29.18±12.11 19.91±8.13
p 0.30 0.002 0.008
Without malleus (n=20) 51.38±9.09 39.00±10.53 12.38±10.39
With malleus (n=55) 49.93±13.14 30.89±13.81 19.05±8.98
p 0.38 0.003 0.02
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Table 7. ABG gain status depending on the ossicular chain status

ABG preoperative ABG postoperative ABG gain
Without stapes (n=31) 29.72±7.62 13.02±10.59 16.69±11.10
With stapes (n=44) 28.41±7.62 4.49±8.37 23.92±7.80
p 0.47 <0.001 0.006
Without malleus (n=20) 31.31±6.30 16.00±10.66 15.31±10.27
With malleus (n=55) 28.09±7.89 5.11±8.39 22.98±9.03
p 0.10 <0.001 0.008
Preoperatively there was no significant difference between the two categories.

Postoperatively PTA-AC was significantly different between S-M- category and S+M+
category. PTA-AC was significantly lower between S-M- group and S+M+ group. (Figure 4,
Figure 5)
Fig. 4. AB gain status depending Fig. 5. AC-PTA status depending

on the ossicular chain status on the ossicular chain status
Discussions
The main objectives of cholesteatoma surgery are to remove the disease and to avoid
recurrences, meanwhile hearing preservation or reconstruction represents a valuable
endeavour. [8]
Considering these targets over time there have been several controversies in the literature
on which is the best surgical technique (canal wall-up versus canal wall down) or which the
best prosthesis that should be used is, or in other words what are the prognostic factors for a
successful surgery. [9, 10] In our study we achieved good results performing canal wall down
procedure, partial mastoid obliteration with choncal cartilage, associated with tympanoplasty.
Ossicular reconstruction was achieved with either a partial or total ossicular replacement
prosthesis. Because this technique involved decreasing the mastoid cavity size, the problems
that usually occur, such as drainage or debris collection, were understated. In addition, re-
establishment of the middle ear space often restored hearing. No cavity problem was seen,
with achievement of an air-bone gap less than 20 dB in 70% of PORP cases and 45% of
TORP cases.
These results are consistent with other studies that have reported similar results analysing
mastoid obliteration techniques. [11-13] However, the hearing results do not depend solely on
the surgical technique or materials used for reconstruction of the sound conduction
mechanism, but also on the stage and severity of the disease. [14] There are several studies in
the literature that have analysed the tympanoplasty prognostic factors. SPITE classification
was proposed by Black who considered groups of factors including surgical, prosthetic,
infection, tissue, and Eustachian tube functionality factors [15]. In another study, Bellucci
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[16] divided cases with good and poor prognosis, taking into account the drainage from the
ear and other craniofacial anomalies. Albu et al., [17] invocated several anatomic and
technical predictive factors and Kartush [18] established MER index. These studies
considered patients with different types of chronic otitis media, patients with different stages
of disease that included cholesteatoma, which makes the results difficult to appreciate. In our
study only cases with cholesteatoma stage II according to the EAONO “Joint Consensus on
Definitions, Classification and Staging of Middle Ear Cholesteatoma” were included. [5] In
this analysis the more favourable results in terms of hearing were obtained for attic
cholesteatoma compared with pars tensa cholesteatoma, which is in agreement with other
studies results. [19-21] These findings can be explained by the fact that in the tensa type of
cholesteatoma the stapes was frequently eroded, which required the use of a total ossicular
replacement type of prosthesis, condition in which the functional results were less favourable,
which confirms the results reported in the literature. [22-23] It is known that the presence of
active inflammatory disease in the tympanic cavity represented an unfavourable prognostic
factor. [24-26]
Further studies are required with the inclusion of a larger number of patients who are in the
same stage of the disease and with a longer period of follow-up. There is a necessity in
otology to explore new opportunities for achieving a common international language, a
universally accepted classification of cholesteatoma, an internationally approved classification
of ear surgery techniques to find the best predictor factors for tympanoplasty, to report more
correctly the results of ear surgery. This fact will provide the possibility of comparing
outcomes and improve the surgical techniques.
Conclusions
Our results suggest that tympanoplasty with titanium partial or total ossicular replacement
prosthesis reconstruction offers a stable improvement of the ABG. The tensa type
cholesteatoma, missing malleus, and the presence of granulation tissue in the middle ear are
unfavourable prognostic factors.
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1. Lee DH, Jun BC, Jung SH, Song CE. Deep temporal fascial-periosteal flap for canal wall down
mastoidectomy. Laryngoscope [Internet]. 2006 Dec [cited 2020 Nov 7]; 116(12): pp. 2229-31.
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[Internet]. 1999 [cited 2020 Nov 7]; 120(3): pp. 361-7. Available from:
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3. Iseri M, Ustundag E, Ulubil A, Ozturk M, Bircan O. Synchronous ossiculoplasty with titanium
prosthesis during canal wall down surgery for advanced cholesteatoma: Anatomical and hearing
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consensus statements on the Definitions, Classification and Staging of Middle Ear Cholesteatoma
[Internet]. Vol. 13, Journal of International Advanced Otology. Mediterranean Society of Otology and
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pp. 186-7. Available from: https://pubmed.ncbi.nlm.nih.gov/7675477/
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difference between two proportions. ScientificWorldJournal [Internet]. 2010 May 18 [cited 2021 Feb
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review of the literature [Internet]. Vol. 15, Journal of International Advanced Otology. AVES; 2019
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13. Yamamoto Y, Takahashi K, Morita Y, Ohshima S, Takahashi S. Long-term follow-up results of canal
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961-5. Available from: https://pubmed.ncbi.nlm.nih.gov/24853244/
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Neurotol [Internet]. 2001 [cited 2021 Feb 16]; 22(3): pp. 299-304. Available from:
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18. Kartush JM. Ossicular chain reconstruction: Capitulum to malleus. Vol. 27, Otolaryngologic Clinics of
North America. Elsevier; 1994. pp. 689-715.
19. Motegi M, Yamamoto Y, Tada T, Takahashi M, Sampei S, Sano H, et al., Clinical characteristics of
pars tensa cholesteatoma: A comparative study of area-based classification systems proposed by the
Japanese otological society and the european academy of otology & neuro-otology. J Int Adv Otol
[Internet]. 2019 [cited 2021 Feb 16]; 15(2): pp. 184-8. Available from:
20. Fukuda A, Morita S, Nakamaru Y, Hoshino K, Fujiwara K, Homma A. Short-term hearing prognosis of
ossiculoplasty in pars flaccida cholesteatoma using the eaono/jos staging system. J Int Adv Otol
21. Murphy TP. Hearing results in pediatric patients with chronic otitis media after ossicular reconstruction
with partial ossicular replacement prostheses and total ossicular replacement prostheses. Laryngoscope
22. Bartel R, Cruellas F, Hamdan M, Gonzalez-Compta X, Cisa E, Domenech I, et al., Hearing results after
type III tympanoplasty: incus transposition versus PORP. A systematic review [Internet]. Vol. 138,
Acta Oto-Laryngologica. Taylor and Francis Ltd; 2018 [cited 2021 Feb 16]. pp. 617-20. Available
from: https://pubmed.ncbi.nlm.nih.gov/29355069/
23. Şevik Eliçora S, Erdem D, Dinç AE, Damar M, Bişkin S. The effects of surgery type and different
ossiculoplasty materials on the hearing results in cholesteatoma surgery. Eur Arch Oto-Rhino-
Laryngology [Internet]. 2017 Feb 1 [cited 2021 Feb 16]; 274(2): pp. 773-80. Available from:
24. Wiatr M, Składzień J, Tomik J, Stręk P, Przeklasa-Muszyńska A. Type II tympanoplasty in chronic
cholesteatoma and granulomatous otitis media – Distant results of otosurgery. Adv Med Sci [Internet].
2014 Mar 1 [cited 2021 Feb 16]; 59(1): pp. 44-6. Available from:
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25. Kaylie DM, Gardner EK, Jackson CG. Revision chronic ear surgery. Otolaryngol - Head Neck Surg
26. Wiatr M, Składzień J, Stręk P, Przeklasa-Muszyńska A, Wiatr A. Chronic otitis media with granulation
is a poor prognostic factor for hearing improvement and development of intracranial complications. J
Int Adv Otol [Internet]. 2019 [cited 2021 Feb 16]; 15(1): pp. 12-7. Available from:
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A Particular Clinical Case of Dysphagia in Children
MANOLE Felicia1, CIAVOI Gabriela2, MARGINEAN Emil3,

VENTER Ciprian4, MOHAN Aurel5
1 University of Oradea, Faculty of Medicine and Pharmacy, 1st December Square 10, 410068 Oradea (ROMANIA)
2 University of Oradea, Department of Dental Medicine, Faculty of Medicine and Pharmacy, 1 st December Square 10,
410068 Oradea (ROMANIA)
3 ENT Department of Surgery, Oradea Emergency Clinical Hospital, Faculty of Medicine and Pharmacy, University of
Oradea, 1st December Square 10, 410068 Oradea (ROMANIA)


5 Department of Neurosurgery, Oradea Emergency Clinical Hospital, Faculty of Medicine and Pharmacy, University of

Emails: manole.felicia@gmail.com, gabrielaciavoi@gmail.com, cypry_85@gmail.com, mohanaurel@yahoo.com
Abstract
Regarding dysphagia in pre-school patients there is many different causes and all of this
have different etiological factors, anamnesis and previous history of the onset of the
symptoms can guide the suspicion of etiological diagnosis.
Case report
We described the case of a 6-year-old boy reporting dysphagia for solids for approximately
5 days. No significant symptoms in children were previously referred.
Conclusions
Dysphagia is an impairment of swallowing due to bulb tumour is rare like the first
symptom.
The diagnosis is always difficult, as the symptoms are often nonspecific. It is imperative to
accurately identify and properly manage dysphagia in pediatric age and this is only possible
with an anamnestic, clinical and instrumental process that takes into account an adequate
differential diagnosis.
Keywords: dysphagia, child, tumour
Introduction
Swallowing difficulties (dysphagia) in pediatric populations can have a lot of different

etiological factors and many underlying causes [1].
The assessment of dysphagia requires consideration of disease in the mouth, pharynx, and
esophagus.
The sensitive pharyngeal syndrome: Odynophagia, which is the pain, felt in the pharynx
and is enhanced by swallowing and which irradiates in the ear; Pharynx paraesthesia, which
are various sensations that are accented by the deglutition of the saliva not of food;
Hyperesthesia, which appears in the acute inflammatory processes of the pharynx;
Hypoesthesia which appears when the cranial nerves IX and X are affected.
The digestive pharyngeal syndrome, pharynx dysphagia: which consists of disorders in the
second stage of deglutition. It may manifest itself as follows: The impossibility of introducing
food into the mouth, which appears in tumours or tongue paralysis; The blockage of the food
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in the pharynx which appears in paralysis of the pharynx muscles that belong to the category
of the bulb paralysis (myasthenia gravis); The reflow of the food through the nose, especially
of the liquid food. It appears in velum paralysis, cleft velum and malformations. All these
cause the shortening of the velum and create the possibility of the reflow; Penetration of food
into the airways (larynx, trachea), which appears in anaesthesia of the pharynx and larynx;
Reflow of the food into the mouth is called regurgitation and appears in pharynx obstructions
(stenosis, foreign bodies or tumours). Pharynx regurgitations are different from vomiting
because of the lack of the gastric secretion.
Purpose
Establishing the ethiology of dysphagia in children is an increasingly common challenge
among pediatric pathologists.
Case report
We present one clinical case of a 6-year-old patient from the urban environment, being
requested in an inter-clinical consultation for swallowing disorders that appeared in the last 5
days and that were accentuated in the previous day, adynamism, a food vomit, sleepiness and
loss of appetite. We remember the fact that 3 weeks ago he presented a food vomit. Objective
ENT clinical examination: on pale facies inspection, without latero-cervical
lymphadenopathy, normal bilateral tympanic membranes, free nasal fossae, congestive-free
oropharynx, normotrophic palatal tonsils, tongue with whitish deposits. Swallowing of saliva
performed with difficulty, swallowing disorders suggestive of a pseudobulbar syndrome, the
lateral protrusion of the tongue appears its lateral deviation, unsystematized nystagmus.
Neurological consultation: sleepiness without maintaining a sitting position, not walking
independently, ROT present asymmetric, Babinski positive bilateral.
Computer Tomography of the skull reveal: 2.3/2.2/2 cm space replacement process, is
highlighted in the projection of the spinal bulb with its secondary expansion. The formation is
spontaneous hypodense, with peripheral load with the appearance of a post-civic garland,
being accompanied by the respective adjacent bulbar edema of the bridge. Skull MRI: Bulbar
tumour with significant extended mesencephalic point edema. Corroborating the clinical data
with the paraclinical ones, the diagnosis of: Expansive process at the level of the spinal bulb
is established. The patient was transferred to the neurosurgery department.
Discussion
Another previous study regarding the characteristics of dysphagia in children with cerebral
palsy, related to gross motor function was made by Joon-Sung Kim [2]. This study shows that
dysphagia is closely related to gross motor function in children with cerebral palsy. Silent
aspiration was observed in the moderate to severe cerebral palsy groups. Aspiration is an
important cause of medical problems such as acute and chronic lung disease, and associated
respiratory complications contribute significantly in increasing morbidity and mortality in
these patient groups. Therefore, the authors suggest that early dysphagia evaluation including
videofluoroscopic swallow study is necessary in managing feeding problems and may prevent
chronic aspiration, malnutrition, and infections. Infancy and childhood represent a time of
unparalleled physical growth and cognitive development. In order for infants and children to
reach their linear and neurological growth potential, they must be able to reliably and safely
consume sufficient energy and nutrients [3].
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Conclusion
Swallowing disorders in children that appear in full health without respiratory intercourse
accompanied by vomiting can also sound alarm in the diagnosis. In children headache,
vomiting and dysphagia may be suggestive symptoms for diagnosis-BULBAR TUMOR.
REFERENCES
1. An Unusual Dysphagia for Solids in a 17-Year-Old Girl Due to a Lusoria Artery: A Case Report and
Review of the Literature, Umberto Fanelli et al., Int J Environ Res Public Health. 2020. May 20;
17(10): p. 3581. doi: 10.3390/ijerph17103581.
2. Characteristics of dysphagia in children with cerebral palsy, related to gross motor function Joon-Sung
Kim et al., Am J Phys Med Rehabil. 2013 Oct, 2013 Oct; 92(10): pp. 912-9, doi:
1097/PHM.0b013e318296dd99
3. Pediatric Dysphagia: Physiology, Assessment, and Management Pamela Dodrill et al., Ann Nutr Metab.
2015, 2015; 66 Suppl 5: pp. 24-31. doi: 10.1159/000381372. Epub 2015 Jul 24.
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Case Report: Laterocervical Adenophlegmon in Children
MANOLE Felicia1, MARIN Aurel2, MARIN Maria Alina3, VENTER Ciprian4

1 University of Oradea, Faculty of Medicine and Pharmacy, 1st December Square 10, 410068 Oradea (ROMANIA)
2 ENT Department, Emergency Pediatric Hospital, 68 MOTILOR Str, 400001, Cluj Napoca (ROMANIA)
3 ENT Department, Municipal Hospital, 11 Tabacarilor Street, 400136, Cluj Napoca (ROMANIA)

Emails: manole.felicia@gmail.com, Skinsens@yahoo.com, alinamaria.muntean@yahoo.com, cypry_85@yahoo.com
Abstract
We report one case of a laterocervical adenophlegmon, observed in a 31-month-old child.

Treatment comprised of intravenous antibiotic therapy and laterocervical drainage, of the
collection of pus. The progression was without complication.
Keywords: laterocervical adenophlegmon, child
Introduction
Laterocervical adenoflegmon develops through suppuration of the jugulo-carotid

laterocervical adenopathy, manifested initially in the cervical region and later in the
lateropharyngeal region. The source of infection is usually a bacterial infection of the palatine
tonsils. The parapharyngeal (pharyngomaxillary) space is lateral to the superior pharyngeal
constrictor and medial to the pterygoid muscle. This space connects to every other major
fascial neck space and is divided into anterior and posterior compartments by the styloid
process. The posterior compartment contains the carotid artery, internal jugular vein, and
numerous nerves.
Infections in the parapharyngeal space usually originate in the tonsils or pharynx, although
local spread from odontogenic sources and lymph nodes may occur [1].
Material and Method
We describe one clinical case of female patient, aged 2 years and 7 months, from urban
areas who have the onset of the disease with asthenia, adinamia 7 days ago and 2 days appears
left laterocervical adenopathy with fever 38.5 degree Celsius. At the inspection: tegument
appear pales, tried facies. Anterior rhinoscopy: pale pituitary mucosa. The patient present at
palpation adenomegaly syndrome with multiple adenopathies bigger than 2 cm laterocervical,
submandibular and a 4 cm laterocervical painless farm formation with onset of 1 week after
mild acute and recurrent infection of the superior tract. The patient has subfebrility, refuse of
food with no hepatomegaly. At the exam of the oral cavity, we observe just hypertrophic
palatine tonsils. Paraclinical: Intensely positive acute phase reactants – VSH=104mm/h,
peripheral smear suggestive of bacterial infection. Cervical ecography: left laterocervical
inhomogeneous parenchymatous formation, irregular contour, imprecise delimited dimension
38/36mm. The patients were afebrile. We treat the patient with meropenem, targocid, anti-
inflammatory drugs. In the 5 days after admission of the hospital, appears laterocervical
adenopathy swelling with redness of the skins without fluctuation at palpation reason for
which it is decided to perform head and neck computer tomography. The child present
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palidity and septic appearance. Laterocervical adenopathy appear like tumour formation with
celsian semen, painful, fluctuating. Associated clinical sign: cough dry, the circulatory
balance was good and normal relation at the exam of nervous system.
Paraclinical examination: head and neck computer tomography (Fig. 1) reveal: fluids
collections and multicloazoned parafluids (Fig. 2) of 5-25mm localized in the left pharyngeal
wall posterolateral which protrudes into the lumen (Fig. 3), with the diminish of this and also
the prevertebral and left parapharyngeal space. The left jugulocarotidian vascular package is
diverted to the side but with preserved flow. Multiple jugulocarotid and posterior cervical
adenopathies with dimensions 4-12mm was described. In conclusion of the computer
tomography examination reveal multicloasonate collection laterocervical and
lateropharyngeal in left side more likely to be a phlegmon.
Blood test: Vsh 107 mm/h, Aslo<7IU/ml, Toxo-IgM-0.051S/CO, CMV-IgG-0.092S/CO,

EBV Capsida IgM-0.355
Positive diagnosis: Laterocervical adenophlegmon

Differential diagnosis: peritonsilar quinsy, osteophlegmon angulomandibular (which
makes the body common with the mandible), retropharyngeal adenoflegmon, TBC
lymphadenopathy, Cystic lymphangioma, Lateropharyngeal tumors, Parapharyngeal tumors,
Vascular malformations: hemangioma, phlebhtazien jugular vein.
Fig. 1 Examination of the lateral neck – sagittal CT images
Fig. 2 Examination CT images, fluids collections and multicloazoned para-fluids
Fig. 3 Examination of the lateral neck – CT images – fluids collections protrude into the
lumen, with the iminish of this and also the prevertebral and left parapharyngeal space.
Treatment
• Surgical-in-stage of suppuration-incision at the anterior edge of the
sternocleidomastoid muscle
• Favourable evolution
Possible complications
• Fatal haemorrhagic complications by damage to large vessels or neurological
phenomena, paralysis of the last four cranial nerves, compression in the posterior
broken hole
Discussions
The collection is located between the vasculo-nervous package of the neck and the
sternocleidomastoid muscle (SCM). Clinically, swelling and laterocervical pain are evident,
which prevents the rotation of the head, gradually installing torticollis and redness of the
neck, by irritation of the cervical plexus and spinal nerve.
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Supraiacent skins are erythematous, with increased local temperature. The general
condition is negatively altered with the presence of fever. On the objective examination, the
palpation-sensitive laterocervical swelling, without fluctuation or with minimal fluctuation
(the thickness of the SCM muscle prevents the perception of fluctuation) is evident.
• The literature mentions that the positive diagnosis must be supported by a positive
punctuation of the collection. We consider that, given the increased risk of incidents
during punctuation (punctuation of the carotid, jugular vein, septic seeding), this
diagnostic test can be performed only in selected cases, otherwise it can be replaced
by ultrasound-guided imaging or punctuation.
• Complications: The most important complications of laterocervical phlegms, in terms
of lethal potential, are mediastinitis, with a mortality rate of over 80%, haemorrhage or
thrombosis of the internal jugular vein and cavernous sinus, cerebral abscess,
meningitis and sepsis.
G Ondzotto [2] reports one case of cervical adenophlegmon is frequently encountered in
children. We report on a case of an exceptional direct communication between a
retropharyngeal abscess and a cervical adenophlegmon, observed in a 25-month-old child.
Treatment comprised double antibiotic therapy and retropharyngeal drainage, which led to
the subsidence of the laterocervical abscess. The progression was uncomplicated.
In another study, the authors [3] made a retrospective study describes a series of 191
children treated for congenital cysts and fistulas of the neck between 1984 and 1999 in the
pediatric ORL Department of La Timone Children’s Hospital. Preauricular fistulas and cystic
hygromas were not included. The anomalies in this series were classified as either
malformations of the midline or malformations of laterocervical region. Malformations of the
midline included the thyroglossal duct cysts (n=102) and dermoid cysts (n=21). The most
common malformations of the laterocervical region were cysts and fistulas of the second cleft
(n=37) followed by those of the first cleft (n=20), those of the fourth pouch (n=7), and thymic
cysts (n=4). Diagnosis of malformations of the midline is usually straightforward. However,
diagnosis of malformation of the laterocervical region can be problematic. Misdiagnosis often
leads to inadequate treatment with recurrence and functional as well as cosmetic sequelae.
Another authors [4] perform one study in which clinical and laboratory features of children
with lymphadenopathy were evaluated. Over a 3-year period, 126 patients were referred to the
clinic for lymphadenopathy. Twenty-eight of cases have diseases mimicking
lymphadenopathy; 98 (mean age: 86+/-55 months) have lymphadenopathy. Localized,
limited, and generalized involvement was found in 52%, 30%, and 18% of patients. The most
common localization was the head and neck region. The causes of lymphadenopathy were
benign diseases in 75 patients.
Sixty percent were reactive lymphadenopathy, 39% were lymphadenitis. Lymphadenitis
was more frequently localized and bigger than 3 cm compared with reactive adenopathy
(p=.02, p=.004). Twenty-three patients have malignant diseases whose mean age was higher
than others (p=.002). The enlargement of supraclavicular nodes was more likely due to
malignant disease (p=.001). The risk of malignant disease was higher in patients who had
generalized lymphadenopathy, lymph nodes bigger than 3 cm, hepatosplenomegaly, and high
lactate dehydrogenase levels. In conclusion, this study pointed out the important clues for the
differential diagnosis, which were present in the history, physical, and laboratory findings.
Conclusions
In the present case evolution was favourable after surgery. We conclude that a minor
swelling in the lateral neck at one child can have rapidly and poor prognostic without
computer tomography investigation and surgical treatment.
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REFERENCES
1. Clarence T. Sasaki, MD, Yale University School of Medicine Parapharyngeal Abscess – Ear, Nose, and
Throat Disorders – By Last full review/revision Nov 2020| Content last modified Nov 2020, MSD
Manual Professional Edition (msdmanuals.com)
2. G Ondzotto, T Fouemina A Oko D Akolbout Childhood laterocervical abscess fistulized in the pharynx:
A case study October 2009 Archives de Pédiatrie 16(12): pp. 1562-4 DOI:
10.1016/j.arcped.2009.09.013
3. R Nicollas, B Guelfucci, S Roman, J.M Triglia Congenital cysts and fistulas of the neck International
Journal of Pediatric Otorhinolaryngology Volume 55, Issue 2, 29 September 2000, Pages 117-124.
4. Nilgun Yaris, Murat Çakir, Emin Sözen, Umit Cobanoglu Analysis of Children with Peripheral
Lymphadenopathy, Clinical Pediatrics 45(6): pp. 544-9, DOI: 10.1177/0009922806290609, August
2006.
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Larynx Papilomatosis-Diagnosis and Treatment
MIHALCEA Cătălin Constantin1, MUNTEANU Simona-Gloria1,2,3,

BEJENARU Paula-Luiza1,3, CONDEESCU-COJOCARIȚA Mihnea Florin1,3,
NIȚU Liliana1,3, BERTEȘTEANU Șerban Vifor Gabriel1,3,
NICOLAESCU Alexandru3,5, POPESCU Bogdan1,3, MITRAN Denisa Maria1,
OTHMAN Amer1, POPA Teodora1, MOȘOIU Anca1, OANCEA Alina Lavinia1,3,
OAȘĂ Irina Doinița1, FLORESCU Elena1, DIACONU Teodora Elena1,
DIMCEA Alisa1, SIREȚEANU Luiza Maria1, NEDELCU Ruxandra Ioana1,
VETRICEAN Iulia1, TUDOSIE Mihai Dumitru1,
TEODORESCU-ARGHEZI Ertan1, ANDRONE Roxana1, MAGDAN Mădălin1,
ENEA Alexandru-Gabriel1, PAVĂL Cristian Costel1, COSTIN Romeo2,
GRIGORE Raluca1,3
1 ENT and Cervico-Facial Surgery Clinic – Colțea Clinical Hospital, Bucharest, (ROMANIA)
2 ENT Clinic and Cervico-facial Surgery – Central Military Emergency University Hospital “Dr. Carol Davila”, Bucharest,
(ROMANIA)
3 Department of ENT and Cervico-Facial Surgery – “Carol Davila” University of Medicine and Pharmacy, Bucharest,
(ROMANIA)
4 ENT Clinic – Emergency County Hospital, Râmnicu Vâlcea, (ROMANIA)
5 ENT Clinic and Cervico-Facial Surgery – MIA Hospital Prof. Dr. Dimitrie Gerota – Bucharest, (ROMANIA)
Email: mihalcea.catalin94@gmail.com
Abstract
Introduction
Laryngeal papillomatosis or recurrent respiratory papillomatosis is the most common
benign laryngeal condition, but with potentially fatal consequences due to its spread along the
airways, the risk of malignancy being low. The incidence of this pathology is bimodal, giving
rise to two distinct forms, namely the juvenile form and the adult form. The juvenile form is
found in about 4 out of 100,000 children and the adult form in 1-2 out of 100,000 adults. The
ethiology of the disease is viral through infection with human papillomatosis virus, subtypes 6
and 11 being the most common. Malignant transformation into carcinoma is more common in
patients infected with subtypes 11, 16 and 18 and patients with juvenile form.

I will present various methods of surgical treatment of laryngeal papillomatosis, such as
ablation of papillomas with cold instruments, CO2 LASER vaporization, angiolytic LASER
treatment, ablation of papillomatous formations with the microdebrider but also methods of
adjuvant treatment.
Results
From a clinical point of view, laryngeal papillomatosis is manifested by dysphonia,
dyspnoea and polypnea, or even inspiratory stridor. It is initially diagnosed by laryngoscopic
examination and the diagnosis is confirmed by biopsy. Surgical principles, regardless of the
technique chosen, must be guided by the precise and careful removal of the tumour formation
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taking into account the preservation of adjacent structures and phonatory function. Of
particular importance is the relationship of the tumour formation with the glottic and
subglottic area where aggressive ablation can lead to vicious scarring and severe dysfunction.
Conclusions
It is important to keep in mind that surgical treatment does not guarantee healing and that
the nature of the infection predisposes to recurrences. Aggressive surgical treatment does not
lead to a reduction in recurrences or a possibility of healing. It should also be understood that
laryngeal papillomatosis is limited to the surface of the epithelium. Adjuvant treatment must
be individualized.
Keyword: larynx, papilomatosis, human papillomavirus, recurrency, dysphonia, dyspnoea
Introduction
Laryngeal papillomatosis or recurrent respiratory papillomatosis or non-keratinized

papillomatosis is the most common benign laryngeal condition. Although a benign disease,
laryngeal papillomatosis has potentially fatal consequences due to its spread along the airways
and the risk, albeit low, of malignant conversion.
Papillomas most often occur from the nostrils, the nasopharyngeal face of the soft palate,
the laryngeal face of the epiglottis (Fig. 2), the upper and lower edge of the laryngeal
ventricle, the vocal cords, the carina and bronchi (Fig. 1). The incidence of this pathology is
bimodal, giving rise to two distinct forms, namely the juvenile form and the adult form. The
juvenile form is found in about 4 out of 100,000 children and the adult form in 1-2 out of
100,000 adults. [1, 2]
Fig. 1. Tracheal location of papillomas Fig. 2. Epiglottic papillomas
The ethiology of the disease is viral, namely the infection with the human papillomatosis
virus.
HPV, belonging to the Papovaviridae family, is a small deoxyribonucleic acid (DNA)-
containing, nonenveloped, icosahedral (20-sided), capsid virus with a double-stranded circular
DNA of 7900 base-pairs long. HPV is epitheliotropic (infects epithelial cells). The HPVs
have been grouped on the basis of shared genetic code homology, with viruses that share less
than 90% identity in specific regions of the virus being defined as separate types. On this
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basis, the HPVs are numbered to distinguish them. Nearly 100 different HPV types have been
identified.
Grouping HPV types based on their DNA homology has allowed us to identify closely
related types. Functionally, these groupings correlate with their tissue preference as well as
similar pathophysiology. [5]
The most common viral subtypes identified are HPV 6 and HPV 11. Recurrent respiratory
papillomatosis is the response of the respiratory mucosa to HPV infection. Papillomas can
develop on any surface of the mucosa of the upper respiratory tract. Viral subtypes of HPV
may be correlated with disease severity and clinical course. (Fig. 3, Fig. 4)
Therefore, patients infected with subtype 11 appear to have a faster growth of papillomas,
which causes a more aggressive form of the disease, recurrences are more frequent, extensive
damage to the respiratory tract and an increase in the number of tracheotomies in these
patients.
Fig. 3. Extensive Disease Fig. 4. Limited Disease
The incidence of malignant transformation into carcinoma in patients diagnosed with

recurrent respiratory papillomatosis is between 1% and 7%. Malignancy is more common in
patients infected with subtypes 11, 16 and 18, patients previously exposed to radiation therapy
and patients with juvenile form. [4]
From a clinical point of view, laryngeal papillomatosis is manifested by dysphonia
sometimes up to aphonia, dyspnoea and polypnea, with shortened breathing time or even
signs of acute obstructive respiratory failure, inspiratory stridor. Inasmuch as the vocal fold is
usually the first and predominant site of papilloma lesions, hoarseness is the principal
presenting symptom in recurrent respiratory papillomatosis. Stridor is often the second
clinical symptom to develop, beginning as an inspiratory noise and becoming biphasic with
progression of the disease. [1, 5]
It is initially diagnosed by laryngoscopic examination after which we observe papillomas
that appear as a whitish exophytic or sessile mass, peduncled or with a wide implantation
base.
The diagnosis is confirmed by biopsy. (Fig. 5) [5]
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Fig. 5. Therapeutic management of recurrent respiratory papillomatosis
Materials and Methods
I will present various methods of surgical treatment of laryngeal papillomatosis, such as

ablation of papillomas with cold instruments, CO2 laser vaporization, angiolytic laser
treatment, ablation of papillomatous formations with the microdebrider but also methods of
adjuvant treatment. For this paper the information was researched and studied in specialized
literature, scientific articles on the methodology of diagnosis and treatment of laryngeal
papillomatosis.
Results
The surgical principles, regardless of the chosen technique, must be guided by the precise
and careful removal of the tumour formation taking into account the preservation of adjacent
structures and phonatory function. Of particular importance is the relationship of the tumour
formation with the glottic and subglottic area where aggressive ablation can lead to vicious
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scarring and severe dysfunction. Preserving even small areas of mucosa with an intact layer of
its own lamina can lead to an impressive difference in phonatory function.
The main indications for surgery in this pathology are represented by obtaining a definite
diagnosis by histopathological examination, maintaining adequate airways and vocal cord
function.
One of the microsurgical methods used is laryngoscopy suspended with papilloma ablation
and LASER vaporization. This method should be applied as rarely as possible to avoid the
formation of possible scars and stenoses. We can use the LASER to excise large tumours or
superficial vaporization. For excision, preferably the LASER should be focused, set to a
maximum of 4W and with a pulse frequency between 0.1 and 0.5 seconds. If you want to
vaporize smaller lesions, we will keep the previous setting but the spot will be defocused.
Recurrences will be approached in the same way.
If we are dealing with a post-interventional laryngeal stenosis, it can be approached by the
same surgical technique for the purpose of cutting or coagulation. To prevent stenosis of the
anterior commissure (Fig. 6), a LASER incision is made at this level. If an interaritenoid
stenosis is found, the incision of the arytenoid mucosa and the vaporization of the submucosal
scars between the arytenoids are performed.
Fig. 6. Stenosis of the anterior commissure Fig. 7. Interaritenoid stenosis
The advantage of the LASER CO2 technique, as opposed to ablation with cold and
electrocoagulation instruments, offers better haemostasis.
Angiolytic LASER treatment in which the wavelength of the laser energy is between 585
and 595 nm, the pulse frequency is between 0.45 to 40ms. LASER energy is selectively
absorbed by oxyhemoglobin and results in intravascular coagulation in the target tissue. Early
studies show a regression comparable to the LASER CO2 technique and a reduction in the
risk of damage to normal tissue.
As an adjuvant treatment, antiviral therapy is based on three antiviral agents.
Intralesional injection of Cidofovir has begun to gain in importance. The injected doses are
between 2 and 57 mg, the frequency of administration is between 2 and 8 weeks and the
duration of antiviral treatment can be extended up to years. The use of Cidofovir is
recommended for severe cases with frequent relapses that predispose to important structural
and functional changes in the larynx. Long-term treatment with Cidofovir predisposes to
adverse effects as well as non-phototoxicity and the risk of carcinogenesis.
α-interferon is considered the drug of choice. Its long-term administration led to complete
remissions in 40% of patients and improvement of symptoms in another 40%
Indole 3- carbinol is also used successfully in the treatment of recurrent papillomatosis as
adjuvant therapy. (1, 2, 3)
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Conclusions
It is important to keep in mind that surgical treatment does not guarantee healing and that
the nature of the infection predisposes to recurrence because eradication of the virus is not
possible. Aggressive surgical treatment does not lead to a reduction in recurrences or a
possibility of healing. It should also be understood that laryngeal papillomatosis is limited to
the surface of the epidermis. Adjuvant treatment should be individualized based on the
frequency and morbidity of surgery, the recurrence pattern of papillomas but also on the side
effects of these therapeutic agents.
REFERENCES
1. European Manual of Medicine Otorhinolaryngology, Head & Neck Surgery – M. Anniko et al.
2. Tratat de chirurgie – otorinolaringologie si chirurgie cervico-facială – Codruț Sarafoleanu et al.
3. Oxford Handbook Otolaryngology and Head and Neck Surgery – Giles Warner et al.
https://doi.org/10.1155/2020/3526316.
https://doi.org/10.1007/s10103-019-02934-x.
author), Iovanescu, G. Experimental and Therapeutic Medicine 18, no. 6(2019): pp. 5082-5087
https://doi.org/10.3892/etm.2019.7857.
doi: 10.3892/etm.2019.7635. Epub 2019 May 31.
2016, Vol. 1 (20), pp. 380-383.
12. Cummings Otolaryngology – Paul W. Flint et al.
13. https://entokey.com/recurrent-respiratory-papillomatosis-2/
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Paragangliomas – Therapeutic Management – Review

MUNTEANU Simona-Gloria1,2*, PAUN Oana-Alexandra4, GRIGORE Raluca2,3,
NITU Liliana2,3, POPESCU Bogdan2,3, CONDEESCU-COJOCARITA Mihnea2,3,
SIMION ANTONIE Catrinel Beatrice2, BEJENARU Paula Luiza2,3,
CIRSTEA Anca Ionela3, OASA Irina Doinita3, RUJAN Simona-Andreea3,
TAHER Bianca Petra3, OTHMAN Amer3, VETRICEAN Iulia3,
TUDOSIE Mihai Dumitru3, NEDELCU Ruxandra Ioana3,
DIACONU Teodora Elena3, SIRETEANU Luiza3, PAVAL Cristian Costel2,3,
MAGDAN Madalin3, ENEA Alexandru-Gabriel3,
MIHALCEA Catalin Constantin3, COSTIN Romeo1,
BERTESTEANU Serban Vifor Gabriel2,3
2 University of Medicine and Pharmacy “Carol Davila”, Bucharest, (ROMANIA)
3 Coltea Clinical Hospital, Bucharest, (ROMANIA)
4 Caunty Emergency Hospital Ramnicu Valcea, Valcea, (ROMANIA)
* Correspondent author: MUNTEANU Simona-Gloria
Emails: gloriamunteanu@gmail.com, oana_paun88@yahoo.com, ralucagrigore.orl@gmail.com,

catrinel_antonie@yahoo.com, pascupaula0205@gmail.com, cirsteaancaa@gmail.com, irinaoasa@gmail.com,
simonaar28@yahoo.com, biataher@gmail.com, othman.amer@yahoo.com, vetricean@gmail.com, mihai.tudosie@scout.ro,
ruxandraioanan@yahoo.com, teodora_diaconu@yahoo.com, luiza.sireteanu@gmail.com, paval.cristi@ygmail.com,
madalin.magdan@gmail.com, alexandru_enea@rez.umfcd.ro, mihalcea.catalin94@gmail.com, cromeorl@yahoo.com,
vifor2001@yahoo.com
Abstract
Introduction
Paragangliomas represent a fairly low percentage of all tumours in the head and neck.
They are generally considered to be soft tissue tumours, but because they present a unique
clinical picture at the outset and various systemic and imaging methods are required for
accurate diagnosis and treatment, they are approached as a separate entity. [1, 2, 3, 4]
Clinical features and classification

These tumours fall into three broad categories, depending on the structure from which they
develop: jugulo-tympanic paragangliomas, vagal paragangliomas and carotid paragangliomas.
Their clinical picture differs from case to case, but in general patients remain
asymptomatic for a long time, the diagnosis being often made incidentally, through an
imaging examination for another desease. [3, 4, 5, 6, 12, 13, 14, 15]
Treatment
The treatment of head and neck paragangliomas has evolved a lot nowadays, and the
therapeutic strategy is based on the size and location of the tumour, the surgical risk, the age
and profession of the patient and on the potential risk of injury of the lower cranial nerves. [7,
8, 9, 10, 16]
Conclusions
Skull base parangangliomas are rare tumours, even in major reference neurosurgical
centers, and remain challenging due to their vascularized nature and deep intra/extracranial
location.
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These tumours may involve the jugular bulb, middle ear, petrous tip, clivus, carotid artery,
infratemporal and posterior fossa.
Despite their benign nature in most cases, these tumours tend to invade adjacent structures,
which can sometimes prevent complete resection of these lesions. To achieve a good clinical
result, close collaboration between ENT surgeons, neurosurgeons and interventional
neuroradiologists is of paramount importance. [12, 13, 15]
Keywords: paragangliomas, head and neck tumours, carotid paragangliomas, jugulo-tympanic paragangliomas,
vagal paragangliomas
Introduction
Paragangliomas represent a fairly low percentage of all tumours in the head and neck.
They are generally considered to be soft tissue tumours, but because they present a unique
clinical picture at the outset and various systemic and imaging methods are required for
accurate diagnosis and treatment, they are approached as a separate entity. These tumours are
conglomerates of neural cells of the sympathetic system and usually reside in the adventitia of
blood vessels or nerves. For this reason, this type of tumour is secreting catecholamines, but
those of head and neck are generally of parasympathetic origin and are not secreting. [1, 2, 3,
4, 5]
Clinical features and classification
From the point of view of location, the vast majority of glomic tumours appear in the
jugulo-tympanic, vagal body and carotid body region. Usually, these tumours are diagnosed
in the elderly and are benign, but there are certain mutations in their genetic structure, which
occur in about 10% of all glomerular tumours, which turn them malignant. Also, almost 10%
have bilateral and multifocal localization, especially in those with a family history of
paragangliomas. [2, 3, 4, 6]
Carotid body tumours are the best represented category among paragangliomas of the head
and neck. These are also called chemodectomas or non-cromaffin paragangliomas. They are
located at the level of the common carotid artery bifurcation, are slow-growing and extremely
vascularized tumours, and most of them are benign. Clinically, a tumour mass located in the
upper part of the neck, or at the level of parapharyngeal space is visible and palpable, where it
pushes medially the lateral wall of the oropharynx. The Shamblin classification divides these
tumours into 3 categories according to their relationships with the carotid arteries and
adjacent nerves (superior laryngeal nerve and hypoglossal nerve). (Fig. 1) [3, 4, 5, 7, 13, 16]
Fig. 1. Shamblin classification of the carotid body paragangliomas – https://doi.org/10.1016/j.jvs.2012.03.037
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Temporal paragangliomas involve tympanic and jugular tumours. They arise from nearby
structures and are sometimes classified into a single group. Tympanic paragangliomas (TP)
are mostly small tumours located in the middle ear. Pulsatile tinnitus is the main symptom in
the vast majority of patients. Hearing loss is present from the beginning in about half of the
patients.
Most TPs are visible by careful otoscopic examination as a vascular mass of the middle
ear, through the translucent eardrum. The introduction of a positive pressure in the external
auditory canal stops the pulsations of the tumour. Frequently, it is impossible to visualize the
entire tumour by clinical examination, so computed tomography (CT) or magnetic resonance
imaging (MRI) are the diagnostic procedures.
Jugular paragangliomas (JP) appear around the jugular bulb. Venous flow occlusion occurs
when these tumours grow in size. As a result, the venous blood in the brain moves to the
sigmoid sinus and the unaffected jugular bulb. The symptoms are similar to those of TP;
pulsatile tinnitus is a common symptom as well, and also a noise can be heard by placing a
stethoscope over the ear. Transmission hearing loss is seen with the progression of the
tumour, which either causes damage to the vibrations of the bones or invades the bones
behind the eardrum. Sensory hearing loss and/or dizziness is reported by the patient when the
tumour has invaded the inner ear. Occasionally, JPs can cause deficits in other cranial nerves
and can create dysphagia and dysphonia. However, due to the relatively slow growth,
swallowing and contralateral phonation can compensate for and initially mask the symptoms
of the disease. When these tumours grow, they can also invade the facial nerve, leading to
facial paralysis, or they can enclose the hypoglossal nerve, leading to paralysis of half of the
tongue. Subsequent growth can lead to compression of the brain and/or brainstem. [18-24]
Fish classification is the one used to destinguish the types of jugulo-tympanic
paragangliomas. (Fig. 2). [6, 8, 9, 10, 15]
Fig. 2. Fish classification used for jugulo-tympanic paragangliomas – www.slideshare.net
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There is also another classification of Fish, adapted by Mattox, which gives details about
localisation and extension of the jugulo-tympanic glomus. (Tab. 1)
Class Location and extension of paraganglioma
A Paragangliomas that arise along the tympanic plexus on promontory
B Paragangliomas with invasion of the hypotympanon; cortical bone over jugular bulb intact
C1 Paragangliomas with erosion of the carotid foramen
C2 Paragangliomas with destruction of the vertical carotid canal
C3 Paragangliomas with involvement of the horizontal portion of the carotid canal; foramen lacerum
intact
C4 Paragangliomas with invasion of the foramen lacerum and cavernous sinus
De 1/2 Paragangliomas with intracranial but extradural extension; De 1/2 according to displacement of the
dura (De1 = less than 2 cm, De2 = more than 2 cm)
Di 1/2/3 Paragangliomas with intracranial and intradural extension; Di 1/2/3 according to depth of invasion
into the posterior cranial fossa (Di1 = less than 2 cm, Di2 = between 2 and 4 cm, Di3 = more than 4
cm)
Tab. 1. Classification of jugulo-tympanic paragangliomas according to Fisch and Mattox
Treatment
The therapeutic management of paragangliomas has evolved a lot in the last 2 decades due
to a deeper understanding of their evolution. However, the treatment of choice remains the
surgical resection. Good postoperative results can be expected in Shamblin tumours of even
6-7 cm, without extension in the skull base. On the other hand, surgery of a paraganglioma
that develops around the cranial nerves is associated with increased morbidity. The slow
growth and tendency of hereditary paragangliomas of the head and neck to be multifocal may
justify less aggressive treatment strategies, with studies showing that surgery in some cases
produces more deficits than the natural evolution of the tumour. [9, 10]
The selection of the type of treatment is made according to the size and location of the
tumour, the age and profession of the patient, the surgical risk, and the potential risk of
producing cranial nerve deficits compared between surgical and non-surgical treatment. [9,
10, 11, 12]
Non-surgical treatment
Observation. It is a therapeutic attitude applicable to all patients, once the diagnosis has
been established. This is done through serial imaging investigations and annual MRI. The
appearance of new symptoms or the rapid increase in the size of the tumour are aspects to
consider in terms of surgery.
Radiotherapy. In elderly patients with advanced tumours, a wait & scan approach is
recommended, and radiotherapy is initiated only when rapidly growing tumours are detected.
Following this, temporary paralysis of the cranial nerves is described and the risk of
malignant transformation of the tumour over time after irradiation must be considered. For
this reason, it is a therapeutic strategy that should be avoided in young patients.
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Surgical treatment
The indications for this treatment depend on several factors related to the tumour and the
patient. Tumour factors are malignancy, rapid growth or local compression. The factors
related to the patient are represented by the severity of the symptoms and the level of
apprehension. Surgical excision of small paragangliomas usually result in transient paralysis
of a single cranial nerve, but if the tumours are large/extensive at the skull base, the resulting
nerve deficits comprise several cranial nerves, they are usually permanent, and the patient has
an increased postoperative morbidity.
Temporal bone paragangliomas are usually differentiated into TP and JP, based on the
Fisch classification, the feasibility of (complete) surgical resection being estimated by the
surgeon.
Surgical resection is the treatment of choice for patients with TP or JP.
Tympanic paragangliomas are usually classified as Fisch A and B. Surgical removal is the
treatment of choice. No major postoperative complications are expected, such as cranial nerve
deficits, but minor complications may occur, such as postoperative conductive hearing loss. In
cases classified as Fisch A and B, a transmeatal or surgical approach by mastoidectomy,
including posterior tympanotomy and facial nerve exposure, may be appropriate. In some
cases of TP classified as class B, a juxtacondylar approach may be required. Fish B class
paragangliomas are in turn divided into 3 other categories. Those in B1 are resolved by canal
wall-up mastoidectomy and posterior tympanotomy. To the approach of those in class B2 is
added the tympanotomy at the level of the facial recess. B3 paragangliomas are operated on
by subtotal petrosectomy and obliteration of the mastoid with abdominal fat. [2-10]
Jugular paragangliomas are classified as Fisch C and D tumours. Due to the development
and implementation of microsurgical techniques, it is possible to completely resect these
tumors, and local control of the tumour can be performed in 80-90% of cases. JPs (Fisch
classification C and D) are usually resected by an infratemporal approach. Tumours classified
as Fisch C1, C2 and De, Di1/2 may require a variant of the juxtacondylar approach. It is
important to note that because these tumours are adherent and occasionally invade the cranial
nerves IX-XII, a higher risk of complications in terms of postoperative nerve deficit is
anticipated. Therefore, patients may have problems, including dysphagia, dysphonia,
weakness of the shoulder joint. Consequently, these patients may need additional surgical
procedures in an attempt to correct these complications. In general, tumours classified as
Fisch Di1/2 should be resected by a two-stage procedure, together with a multidisciplinary
team, involving the neurosurgeon. However, this therapeutic option is not available for
patients classified as Fisch Di3 (in these cases, palliative radiotherapy is recommended). The
current literature shows that the long-term success rate after JP surgical therapy is 72-95%;
however, it should be noted that the comparison of results from different studies is difficult
because parameters such as the Fisch classification and follow-up intervals are not consistent
between studies. [1-9]
Conclusions
Skull base parangangliomas are rare tumours, even in major reference neurosurgical
centers, and remain challenging due to their vascularized nature and deep intra/extracranial
location.
These tumours may involve the jugular bulb, middle ear, petrous tip, clivus, carotid
arteries, infratemporal and posterior fossa. [17, 18]
Despite their benign nature in most cases, these tumours tend to invade adjacent structures,
which can sometimes prevent complete resection of these lesions. To achieve a good clinical
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result, close collaboration between ENT surgeons, neurosurgeons and interventional

neuroradiologists is of paramount importance.
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Primary Squamous Cell Carcinoma of the Parotid Gland – Case

Review
NEDELCU Ruxandra Ioana2, GRIGORE Raluca1,2, POPESCU Bogdan1,2,

NIȚU Liliana1,2, OANCEA Alina1,2, BEJENARU Paula Luiza1,2,
SIMION-ANTONIE Catrinel Beatrice1,2,
CONDEESCUCOJOCĂRIȚĂ Mihnea1,2, NICOLAESCU Alexandru1,4,
CÎRSTEA Anca Ionela2, MUNTEANU Gloria Simona1,2,3,
DIACONU Elena Teodora2, DIMCEA Alisa2, RUJAN Simona Andreea2,
SIREȚEANU Luiza Maria2, TAHER Bianca Petra2, OTHMAN Amer2,
POPA Teodora2, OAȘĂ Irina2, MITRAN Denisa2, FLORESCU Elena2,
COSTIN Romeo3, ANDRONE Roxana2, VETRICEAN Iulia2,
MAGDAN Mădălin2, PAVĂL Cristian Costel2, ENEA Alexandru Gabriel2,
BERTEȘTEANU Șerban Vifor Gabriel1,2
1 University of Medicine and Pharmacy Carol Davila (ROMANIA)
2 “Coltea” Clinical Hospital (ROMANIA)
3 “Carol Davila” Central Military Emergency University Hospital (ROMANIA)
4 MAI Hospital Prof. Dr. Dimitrie Gerota (ROMANIA)
* Corresponding author: NEDELCU Ruxandra Ioana
Email: ruxandraioanan@yahoo.com
Abstract
Cancer of the parotid gland is relatively rare, but carries poor prognosis due to its
prevailing distant metastases. Primary squamous cell carcinoma (PSCC) of the salivary gland
is a rare and aggressive disease, that most commonly affects males in the sixth decades of life.
It is a fast-advancing tumour with high morbidity and mortality rates. Despite of the
complete removal of the salivary gland and postoperative radiotherapy, the prognosis of this
cancer continuous to be poor. Primary squamous cell carcinoma must be differentiated from
other primary malignancies of the salivary gland and metastatic squamous cell carcinoma;
therefore, a carefully clinical and histological examination are mandatory. The present paper
describes a case of an 84-year-old patient suffering of advanced parotid cancer with facial
nerve involvement. The patient presented with a progressively increasing, painless mass in the
left parotid region. An initial fine needle aspiration (FNA) cytology was performed and the
squamous cell carcinoma histological result was revealed. As no other primary source was
found in this case, the final diagnosis of primary squamous cell carcinoma of the parotid was
confirmed.
Keywords: salivary glands, otorhinolaryngology, neoplasm
Introduction
Cancers of the salivary glands are relatively rare, but they have a large variety of
histological subtypes (mucoepidermoid carcinoma, adenoid cystic carcinoma, acinic cell
carcinoma, squamous cell carcinoma). The majority of salivary gland tumours arise in the
parotid glands.
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Primary squamous cell carcinoma of the parotid gland is a rare cancer including less than
1% of all salivary gland cancers. Invasion from an adjacent squamous cell carcinoma or
metastasis that involves a major salivary gland is a more common situation and these should
always be excluded before considering it a primary parotid tumour [1]. The studies proved the
cases are to be found more often in men than in women. It can occur in people of all ages, but
the average age is in the sixth decades of life. Radical surgery and adjuvant radiotherapy is the
gold standard treatment. According to the extension of the primary tumour into the neck, neck
dissection may be necessary [2].
Patients will need to have follow-up exams for the rest of their lives. They also must avoid
consumption of tobacco and alcohol in order to reduce the risk of the second cancer.
In the present case report, we present a particular case of a primary squamous cell
carcinoma of the parotid gland with facial nerve involvement. This case is about an 84-year-
old man who presented with a progressively increasing, painless mass in the left parotid
region with a six months duration. An initial fine-needle aspiration cytology and subsequent
histopathological examination confirmed that the tumour was squamous cell carcinoma. As
no other primary source could be demonstrated in the patient, the final diagnosis was primary
squamous cell carcinoma (PSCC) of parotid.
Case Presentation
An 82-year-old smoker male presented with painless mass around his left angle of
mandible which was progressively increasing over the last 6 months. There was no history of
prior mass in the same region. The clinical examination revealed a tumour measuring about
5×5 cm in the left parotid region, firm to hard in consistency, non-tender, fixed to the skin and
to the deeper tissues, as well as a left facial paralysis. Cervical lymph nodes were not
palpable. A provisional diagnosis of parotid tumour was made.
Fig. 1. A massive left parotid tumour with facial nerve involvement
Investigations
Fine-needle aspiration cytology (FNAC), from the lesion, showed few clusters of
squamous cells. A diagnosis of squamous cell carcinoma was made and the patient went to
further workup for identifying the primary site. The patient had no history of haemoptysis,
dyspnoea, difficulty in swallowing, changes in his voice or treatments for any cancer in the
past. Careful inspection of the skin of head, neck and scalp was performed to detect any
lesions, but none were observed.
Thorax radiography and otorhinolaryngological examinations were within normal limits.
Computed-Tomography Examination of head, neck and thorax revealed a tumour of the
profound lobe of the left parotid gland and a few submandibular lymph nodes, with maximum
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11 mm in diameter. As no other primary source was demonstrated the possibility of the

primary source being the parotid itself was strongly considered. The surgical treatment
consisted in total parotidectomy with facial nerve resection. Gross examination of the
specimen showed an irregular, hard tumour measuring 5×4 cm. Microscopically, the tumour
was composed of single population of moderately differentiated malignant squamous cells.
With no other demonstrable primary source of origin, a final diagnosis of primary
squamous cell carcinoma of parotid gland was offered.
Fig. 2. The surgical specimen showing monobloc excision of the tumour
Differential Diagnosis
The differential diagnosis of any tumour with squamous cell differentiation in the parotid
region should include high-grade mucoepidermoid carcinoma and metastatic squamous cell
carcinoma from a distant primary or a direct extension from an adjacent primary skin
carcinoma.
Mucoepidermoid carcinomas are seen throughout all adult age groups but are most
common in middle age (35-55 years). However, it is the most common malignant salivary
gland tumour of childhood. A slight female predilection has been described. Mucoepidermoid
carcinomas represent a distinct type of tumour. They contain three cellular elements in
varying proportions: squamous cells, mucus-secreting cells, and “intermediate” cells. The
most common etiologic factor in the development of mucoepidermoid carcinoma is radiation.
In our case, the patient was 84-year-old man with no treatment history for other cancers in
the past. Histopathological examination from the tumour showed only populations of
malignant squamous cells so the probability of mucoepidermoid carcinoma was not
considered.
Secondary neoplasia in the parotid gland is increasingly frequent. The parotid gland has
unique development from ectodermal outpouchings, which encapsulate the mesoderm-derived
lymphatic system. This results in a wide lymphatic drainage basin from the head and neck to
the parotid gland. The highest proportion of parotid metastases have been reported to arise
from squamous cell carcinoma of the skin of the scalp, face and neck, but their frequency
varies between populations in different geographical locations with different levels of sun
exposure [3, 4, 5]. However, rarely, malignancies of the upper aerodigestive tract will
metastasize to the parotid gland. Squamous cell carcinoma is the second most common
subtype of skin cancer after basal cell carcinoma and accounts for 20% of all non-melanotic
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skin cancers in the head and neck area [6]. It is mandatory to inspect the skin of head, neck
and scalp for any tumour or ulcerative lesion. Also, metastatic upper aerodigestive tract
malignancies, although rare, should be considered when evaluating patients with parotid
masses. In the present case, a primary malignancy in any other organ could not be found from
patient’s history, clinical examination and investigations. As such, possibility of parotid being
the secondary site was excluded.
Treatment
Based on the initial workup results and FNAC report, the patient underwent total
parotidectomy with facial nerve resection. Following the histopathological examination and
final diagnosis of PSCC, he received adjuvant radiation therapy.
Fig. 3, 4. The postoperative appearance of the patient 7 days after surgery
Outcome and follow-up

The patient is good on follow-up examinations, after 5 months of surgery and adjuvant
radiation therapy, without any signs of recurrence.
Discussion
Squamous cell carcinoma originating in the parotid gland is a rare malignancy that
accounts for less than 1% of all salivary gland cancers. The most of the cases arise in the
parotid gland while the rest are found in submandibular gland.
Primary squamous cell carcinoma of parotid is an aggressive tumour of the elderly with a
mean age of presentation at 60 years and is found twice often in men than in women. These
tumours are frequently associated with a rapid death. Radiotherapy in the past has been
implicated as a predisposing factor for PSCC. The most of the patients usually present in an
advanced stage and with facial nerve involvement or cervical metastases [7]. The prognosis is
poor even with radical surgery and adjunctive radiotherapy.
Fine-needle aspiration cytology is the preferred initial investigation in tumours of major
salivary glands. Careful clinical and histological review is necessary to differentiate primary
squamous cancer of the parotid from metastases or other primary parotid malignancy.
Primary squamous cell carcinomas are solid, bulky tumours with occasional foci of
necrosis on cut section. Histopathologically, the most of the tumours are moderately to well
differentiated squamous cell carcinomas with desmoplastic stroma and evidence of perineural
invasion or soft tissue extension. Intracellular mucin is absent and mucin stains are negative.
It can often be encountered squamous metaplasia and dysplasia of adjacent salivary ducts.
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Cervical lymph node metastasis is frequently observed [1], [7].

Primary squamous cell carcinoma of salivary glands is a high-grade aggressive malignancy
which has a worse prognosis than conventional squamous cell carcinoma. Advanced age,
facial nerve involvement and cervical lymph node metastasis are associated with significantly
poor prognosis [1], [8], [9], [10]. Surgery remains the mainstay of definitive treatment of
salivary gland cancers. However, radiation plays a significant role as adjuvant treatment for
primary squamous cell carcinoma. Adjuvant radiotherapy has improved local and regional
control.
Although these tumours are frequently associated with rapid death [11], [12].
Conclusion
Salivary gland cancers are less common and therefore there is no widely recommended
screening program to diagnose them as early as possible. Moreover, these types of cancers
represent a therapeutic challenge for both the surgeon and patient. Primary squamous cell
carcinoma of the parotid gland patients is often elderly with remarkable medical
comorbidities.
The side effects of the therapy are difficult to be predicted and the prognosis is poor.
The treatment for this kind of pathology involves multidisciplinary care. Total
parotidectomy for the removal of the tumour and postoperative radiotherapy is the standard
treatment. The need for sacrifice of the facial nerve remains an intraoperative decision.
All al the patients must have regular follow-up examinations, every three months in the
first year, every six months for the subsequent three years and annually from the fourth year
onward.
REFERENCES
1. Lewis JE, Olsen KD. Squamous cell carcinoma. In: Barnes L, Eveson JW, Reichart P, Sidransky D,
eds. World Health Organization classification of tumours. Pathology and genetics of head and neck
tumours. Lyon: IARC Press, 2005: pp. 245-6.
2. Elective Neck Dissection in patients with stage T1-T2N0 carcinoma of the anterior tongue By: Mirea,
D.; Grigore, R.; Safta, D.; et al., HIPPOKRATIA, Volume: 18 Issue: 2 Pages: 120-124.
3. Bron LP, Traynor SJ, McNeil EB, et al., Primary and metastatic cancer of the parotid: comparison of
clinical behaviour in 232 cases. Laryngoscope. 2003; 113: pp. 1070-1075.
4. Bergersen PJ, Kennedy PJ, Kneale KL. Metastatic tumours of the parotid region. Aust N Z J Surg.
1987; 57: pp. 23-26.
5. Chua MST, Veness MJ, Morgan G, et al., Parotid lymph-node metastases from cutaneous squamous-
cell carcinomas: treatment outcome and prognostic factors following surgery and adjuvant radiotherapy.
Australas Radiol. 2002; 46: pp. 174-179.
6. Alam M, Ratner D. Cutaneous squamous-cell carcinoma. N Engl J Med. 2001; 344: pp. 975-983. doi:
10.1056/NEJM200103293441306.
7. Cheuk W, Chan JKC. Salivary gland tumours. In: Fletcher CDM, ed. Diagnostic histopathology of
tumours. 2nd edn Philadelphia: Churchill Livingstone, 2000: pp. 287-303.
https://doi.org/10.1155/2020/3526316.
https://doi.org/10.1007/s10103-019-02934-x.
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https://doi.org/10.3892/etm.2019.7857.
doi: 10.3892/etm.2019.7635. Epub 2019 May 31.
14. Combined approach for large tumors of the nose and paranasal sinuses – case report, O. D. Palade,
2016, Vol. 1 (20), pp. 380-383.
16. Ying YLM, Johnson JT, Myers EN. Squamous cell carcinoma of the parotid gland. Head Neck 2006;
2013: pp. 626-32.
17. Flynn MB, Maguire S, Martinez S, et al., Primary squamous cell carcinoma of the parotid gland: the
importance of correct histological diagnosis. Ann Surg. Oncol 1999; 2013: pp. 768-70.
18. Lee S, Kim GE, Park CS, et al., Primary squamous cell carcinoma of the parotid gland. Am J
Otolaryngol 2001; 2013: pp. 400-6.
19. Friedman M, Levin B, Grybauskas V, et al., Malignant tumours of the major salivary glands.
Otolaryngol Clin North Am. 1986; 19: pp. 625-636.
20. Shemen LJ, Huvos AG, Spiro RH. Squamous cell carcinoma of salivary gland origin. Head Neck Surg.
1987; 9: pp. 235-240.
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Laryngological Aspects in SARS-CoV-2 Infection
OANCEA Alina-Lavinia-Antoaneta1,2, ANDRONE Roxana-Gabriela1,

DAYEH Iulia-Irena1, OAȘĂ Irina-Doinița1,
BERTEȘTEANU Șerban Vifor Gabriel1,2, GRIGORE Raluca1,2, NIȚU Liliana1,2,
MOȘOIU Anca1,2, MUNTEANU Simona-Gloria1,2,3, BEJEARU Paula Luiza1,2,
SIMION-ANTONIE Catrinel Beatrice1,2,
CONDEESCU-COJOCĂRIȚA Mihnea1,2, NICOLAESCU Alexandru2,4,
MITRAN Denisa Maria1, FLORESCU Elena Mihaela1, CÎRSTEA Anca Ionela1,
OTHMAN Amer1, POPA Teodora1, NEDELCU Ruxandra Ioana1,
DIACONU Teodora Elena1, TAHER Bianca Petra1, RUJAN Simona-Andreea1,
SIREȚEANU Luiza Maria1, DIMCEA Alisa1, VETRICEAN Iulia1,
MAGDAN Mădălin1, PAVĂL Cristian Cornel1, ENEA Alexandru1,
POPESCU Bogdan1,2
1 ENT, Head and neck surgery department, Coltea Clinical Hospital, Bucharest (ROMANIA)
2 “Carol Davila” University of Medicine and Pharmacy, Bucharest (ROMANIA)
3 ENT, Head and neck surgery department – “Carol Davila” Emergency Central Military Hospital, Bucharest (ROMANIA)
4 MAI Prof. Dr. Dimitrie Gerota Hospital, Bucharest (ROMANIA)
Email: roxanandrone@gmail.com
Abstract
COVID-19 is a contagious disease, which is now declared global pandemic. We will

provide some useful information for oncology patients, especially those with tracheostomy,
“neck breathers”, because they need information to deal with this infection, depression, social
isolation, fibrosis, lymphedema and secretions. They also need to know how to prepare
themselves and cope with a possible admission due to SARS-CoV-2 infection. In the second
part of the paper, we will discuss the implications of COVID-19 in the ENT sphere, especially
at the level of pharynx, larynx and trachea, from the point of view of the medical staff. We
must not forget that during the pandemic, the population continues to develop other diseases
including benign and malignant tumours that continue to appear and evolve.
Keywords: COVID-19, SARS-CoV-2, laryngology, laryngectomized patients, tracheostomy
Introduction
Coronavirus 2019 (COVID-19) is a contagious disease, caused by SARS-CoV-2 virus and

is now declared global pandemic. He is responsible for 90.022.880 cases and 1.933.188
deaths reported at the time of writing [1]. Persons with COVID-19 can show a wide range of
symptoms – from mild to severe symptoms. These symptoms can occur 2-14 days after
exposure to the virus and the most common are fever, coughing and breathing difficulties [2].
At the moment, we can only talk about the experiences so far, because COVID-19 is
constantly evolving both in terms of its implications and complications. Even if the number of
publications on this subject is increasing so far, it is good to bear in mind that everything we
say now can be invalidated in 3 months, 6 months, 1 year, and yet it is good to do it because
in 3 months, 6 months or 1 year, this data will be very useful.
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Information for neck breathers
In the first part we will present some useful information for oncology patients, especially
those with tracheostomy, “neck breathers”, because they need additional information to
handle this infection. Laryngectomees must be warned to be extra vigilant in protecting
themselves because in their case the virus can penetrate the body through the nose, mouth or
conjunctiva and the stoma. The fact that these patients breathe directly through the tracheal
stoma leads to a decrease in pulmonary and respiratory capacity due to atelectasis caused by
the flow resistance damage to upper pulmonary lobes, which will make it more difficult for
them to cope with SARS-CoV-2 infection. In order to prevent the occurrence of atelectasis,
these patients must use a heat and moisture exchanger (HME), perform breathing exercises
with a stimulator adapted for laryngectomy or use diaphragm breathing. To these is added
mucous irritation due to cold, inspired dry air. Also, “neck breathers” should be vigilant
because they are “super spreaders” due to the tracheal stoma. They can minimize aerosols by
using a HME that covers and isolates the stoma, possibly also filtering potential respiratory
pathogens [3], [4].
As self-protection measures for them and others we can list: use of an HME and hand
hygiene before speech; use of a hand free HME – to stop touching HME when speaking; wear
a surgical mask or scarf over the stoma (Fig. 1); wear a different mask over the nose and
mouth and safety glasses or visor; men should shave even if for those with neck dissection
sometimes it may be unpleasant due to the facial numbness, they can use an electric shaver
without causing skin lesions. In addition, wearing masks prevents the laryngectomy from
reaching these areas; hand hygiene for at least 20 seconds or use alcohol-based disinfectant,
especially before touching the tracheal stoma or HME; to prevent the stoma from being
touched with unhygienic hands, the patient may become accustomed to creating a habit of
using non-dominant hand to touch the stoma and dominant hand when performing other
activities; to respect social distance; to disinfect frequently touched objects [5].
Fig. 1. Protective mask over the nose and mouth and an additional mask over the stoma
Laryngectomized patients have an increased risk of developing a life-threatening form of

COVID-19. Favouring factors are: age over 55, pre-existing lung disease, chronic kidney
disease, high blood pressure or heart disease, diabetes, immunosuppression due to radiation
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therapy, chemotherapy of chronic treatment with Prednisone, HIV infection, etc. Also, those
who live with them or take care of them must pay attention to protection measures [6].
Visits to the doctor should be carried out under special conditions of protection for both
patients and health professionals, if the patient shows new signs and symptoms of cancer.
Telemedicine is a viable option for routine controls on stable patients.
Testing these patients for SARS-CoV-2 involves taking two specimens, a nasopharyngeal
specimen and another specimen from the tracheal stoma for viral tests, dosing antibodies for
patients who have had the disease. At this moment it is unknown if the presence of antibodies
protects the person from being reinfected or for how long [7].
Psychological damage to neoplastic patients is common but has been observed a growing
tendency with the onset of SARS-CoV-2 pandemic. Depression, fear of being infected,
anxiety and social stress can lead to suicide. The difficulty of communicating and the daily
struggle to cope with limitations and disabilities are problems that laryngectomized patients
face every day. Among the ways to prevent depression from being installed are: develop
leisure activities, maintaining personal relationships with family and friends, healthy eating,
physical activities and rest. Due to the imposed measures, family can no longer accompany
the patients to consultations, or visit them when they are hospitalized, they no longer receive
instructions about the care or physical and mental support these patients need and so, this
increases the pressure on the patients [8].
Also, when in public, “neck breathers” can experience problems and negative actions from
other people especially in this pandemic context. Therefore, it is good to know that they need
to pay extra attention preparing to go out in public by cleaning the stoma and trachea using
saline. However, if stoma care is needed in public, they can retreat to private places. If they
feel the need to cough, it is indicated to cover their stoma and retreat due to the high risk of
aerosolization at the time of coughing, maintaining a distance of 2 meters is mandatory and
must use both a protective mask over the nose and mouth and an additional mask over the
stoma. In case of possible emergency hospitalization because of SARS-CoV-2 infection,
laryngectomized patients risk receiving improper treatment as they may sometimes not be
recognized as laryngectomees, and may inadequately receive oxygen and their specific needs
are not known to healthcare professionals. Therefore, it is good that the neck breathers have a
prepared folder containing a summary of medical and surgical history, diagnosis and allergies,
an updated list of medication, contact information of the laryngectomee’s physician, speech
therapist, family, friends, a drawing explaining the anatomy of the upper respiratory tract and
where the voice prosthesis is located, paper and pen, wipes, saline buletts, HME filters, HME
cassettes and materials needed to change them, tweezers, mirror [5].
Information for medical staff
In the second part of the paper, we will discuss the implications of COVID-19 in the ENT
field, especially in the pharynx, larynx and trachea, from the perspective of medical staff.
The main target of SARS-CoV-2 is angiotensin-converting enzyme 2 (ACE2) receptors
that are found in the respiratory mucosa, but also in the heart, kidneys, liver and
gastrointestinal tract.
Therefore, it is not surprising that the virus targets these organs. Usually, the lung damage
is most often with the appearance of oedema that leads to fibrosis, to which thromboembolism
is added (heart attacks, deep thrombosis). At their peak is renal failure, combined with renal
thrombosis. In addition to the targeted organs (lungs, heart, kidneys), there are ACE2
receptors in the pharynx, larynx, trachea and it would be surprising not to find a response at
this level.
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Heterogeneity is a very good way to describe the body's response to SARS-CoV-2 [9],
[10], [11].
We must not forget that during the pandemic, the population continues to develop other
diseases (benign tumours that can endanger their lives at some point, and neoplasms continue
to appear and evolve). Researchers in the UK say that in the first month of quarantine alone,
more than 500 cases of laryngeal cancer were missed. We must be aware that this will change
the presentation stage of cancer patients.
In intubated COVID-19 patients, laryngoscopy is required before intubation, tracheostomy
or detubation. It is important to visualize the airways, but this does not mean that we will
perform this procedure on each patient, but only on those with prolonged intubation to which
we can sometimes recommend, depending on findings, local administration of steroids, a
smaller intubation tube or delay the detubation [12].
Laryngoscopic images that were observed in intubated COVID-19 patients show areas of
oedema and granulation, especially subglottic that may extend down to the level where
tracheostomy is performed, supraglottic, glottic, and subglottic ulcerations [13].
Prior to the pandemic, on intubated patients’ tracheostomy was performed between days 7-
14 of orotracheal intubation (OTI). Currently, OTI is extended to 2-3 weeks. The question is
whether inflammation occurs due to prolonged OTI, supine position, pronation, rotation or is
it something specific to this virus. Because ACE2 receptors are randomly distributed in the
mucosa, the lesions described above are randomly distributed, we can hypothesize that these
lesions are caused by COVID-19 and not by prolonged intubation [14], [15].
A problem that raises discussions is represented by tracheostomy. At the opening of the
trachea, the presence of oedema and bleeding due to increased vascular permeability were
observed. We should avoid the use of cautery due to significant aerosolization. Another
problem is changing the tracheal cannula which must be treated as an operation in itself.
Choosing the size of the tracheal cannula is important precisely because of the oedema. In
favour of a smaller cannula pleads the narrowed space due to the oedema, but there is a risk of
air gaps when oedema is reduced. The argument for a larger cannula would be that as the
oedema decreases, there is no need to change the cannula, and the risk of infection of the
medical staff and the number of procedures performed on the patient are reduced.
Bronchoscopy and pulmonary lavage can also be performed on a larger tube. The risks of
choosing a tracheal cannula with a larger diameter are the appearance of tracheal stenosis due
to the pressure exerted on the walls of the trachea and sometimes, although the cannula is
large, there may be air gaps.
Through an effective communication between ICU and ENT we can promptly intervene in
patients who, as a result of anticoagulation, bleed. Sometimes, they can present significant
bleeding in the nose and mouth. Another situation is related to patients who have swelling of
the tongue, face and head due to the presence of angioedema as a result of the effects of
bradykinin. [16].
Discussions
The guides are constantly updated and we need to record as much data as possible and
share this information. Because it is very difficult to work in overalls, we need to use and
develop technology to facilitate communication, possibly Personal Protection Equipment
(PPE) with technology included. Good collaboration between ICU and ENT and very
meticulous planning of each procedural step is required. We must be careful on intubation,
tracheostomy and when changing the tracheal cannula. It is not yet established, but it should
be investigated whether tracheostomy can speed up detubation and release the ventilator
capacity during the COVID-19 pandemic. Stenosis, oedema, and ulceration of the trachea at
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the exact site of the tracheostomy suggest that this procedure may be more dangerous and
may present more postoperative problems than in cases without such changes. It seems that
most people cope well with this disease, but that does not mean that they will not develop
complications on the long term. Mutual support and data collection are key to better
understanding this disease.
REFERENCES
1. Huang C, Wang Y, Li X, et al., (2020). Clinical features of patients infected with 2019 novel
coronavirus in Wuhan, China. Lancet 395(10223), pp. 497-506.
2. Guan WJ, Ni ZY, Hu Y, et al., (2020). Clinical Characteristics of Coronavirus Disease 2019 in China.
N Engl J Med 382(18), pp. 1708-1720.
3. Ho OY, Lam HC, Woo JK, et al., (2004). Tracheostomy during SARS. J Otolaryngol 33, pp. 393-396.
4. Morgan P. (2004). Tracheostomy in a patient with SARS. Br J Anaesth 92, pp. 905-906; author reply 6.
5. Brook I. (2020). The Laryngectomee Guide for COVID-19 Pandemic. Washington DC, USA.
6. Davenport L: ICU Lessons on COVID-19 From Italian Front Line (2020). Be Flexible; (accessed
19.01.2021).
7. Tran K, Cimon K, Severn M, et al., (2012). Aerosol generating procedures and risk of transmission of
acute respiratory infections to healthcare workers: a systematic review. PLoS One 7(4), e35797.
8. Jafari A, Rezaei-Tavirani M, Karami S, Yazdani M, Zali H, Jafari Z. (2020). Cancer Care Management
During the COVID-19 Pandemic. Risk Manag Healthc Policy 13, pp. 1711-1721.
9. Jia HP, Look DC, Shi L, et al., (2005). ACE2 receptor expression and severe acute respiratory
syndrome coronavirus infection depends on differentiation of human airway epithelia. J Virol 79(23),
pp. 14614-21.
10. Ren X, Glende J, Al-Falah M, et al., (2006). Analysis of ACE2 in polarized epithelial cells: surface
expression and function as receptor for severe acute respiratory syndrome-associated coronavirus. J Gen
Virol 87(Pt 6), pp. 1691-1695.
11. To KF, Lo AW. (2004). Exploring the pathogenesis of severe acute respiratory syndrome (SARS): the
tissue distribution of the coronavirus (SARS-CoV) and its putative receptor, angiotensin-converting
enzyme 2 (ACE2). J Pathol 203(3), pp. 740-743.
12. Lee N, Allen Chan KC, Hui DS, et al., (2004). Effects of early corticosteroid treatment on plasma
SARS-associated Coronavirus RNA concentrations in adult patients. J Clin Virol 31(4), pp. 304-9.
13. Oliver CM, Campbell M, Dulan O et al., (2020). Appearance and management of COVID-19 laryngo-
tracheitis: two case reports [version 2; peer review: 2 approved]. F1000Research, 9(310), pp. 1-11.
14. Royal College of Anaesthetists: Royal College of Anaesthetists COVID-19 clinical guidance (2020);
(accessed 19.01.2021).
15. Stell PM, Gregory I, Watt J. (1978). Morphometry of the epithelial lining of the human larynx. I. The
glottis. Clin Otolaryngol Allied Sci 3(1), pp. 13-20.
16. Ahmed N, Hare GM, Merkley J, et al., (2005). Open tracheostomy in a suspect severe acute respiratory
syndrome (SARS) patient: brief technical communication. Can J Surg 48(1), pp. 68-71.
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Risk Factors of Impaired Wound Healing for Head and Neck

Cancer Surgery After Radiation Therapy
OAȘĂ Irina Doinița1, BERTEȘTEANU Ș.V.G.1,2, GRIGORE Raluca1,2,

OANCEA Alina Lavinia Antoaneta1,2, NIȚU Liliana1,2, MOȘOIU Anca1,2,
MITRAN Denisa Maria1, BEJENARU Paula Luiza1,2,
CONDEESCU-COJOCĂRIȚA M.1,2, NICOLAESCU A.2,4, FLORESCU Elena1,
CÎRSTEA Anca Ionela1, OTHMAN A.1, NEDELCU Ruxandra Ioana1,
DIACONU Teodora Elena1, TAHER Bianca Petra1,
RUJAN Simona-Andreea1, SIREȚEANU Luiza Maria1, ANDRONE Roxana1,
IRENA Dayeh1, DIMCEA Alisa1, VETRICEAN Iulia1, MIHALCEA C.C.1,
TUDOSIE Mihai1, MAGDAN Madalin1, PAVĂL Cristian1, ENEA Alexandru1;
POPESCU Bogdan1,2
2 ENT, Head and neck department “Carol Davila” University of medicine and pharmacy, Bucharest, (ROMANIA)
3 ENT, Head and neck surgery department “Carol Davila” Emergency Central Military Hospital, Bucharest, (ROMANIA)
4 ENT, Head and neck surgery department MAI Prof. Dr. Dimitrie Gerota Hospital, Bucharest, (ROMANIA)
Email: dr.alina.oancea@gmail.com
Abstract
Head and neck cancer patients need to undergo curative or paliation therapy. Since there is
a large variety of therapy available multiple choices are made only by consensus achieved in
the oncology committee. Surgery and radiation therapy are more likely to leave marks at the
site of the skin overlying the organ involved in the cancer process. Radiation therapy is one of
the most important methods of controlling head and neck cancer and it can manifest with
different complications at skin level, like dermatitis, necrosis and even organ fistulas. Open
surgery is, without a doubt, the most aesthetic impairing method to treat cancer since
incisions, scaring and wound complications are a known possibility. Impaired healing of each
wound is likely to occur if one or more factors disrupt the normal time frame and evolution of
one or more phases of the healing process. The most important factors we need to take into
account when dealing with a surgical patient are nutrition, infection, diabetes, oxygen levels,
alcohol and tobacco consumption, age and stress. There are several other factors that might
impede with normal healing but we found that these are the most common in our series of
patients. Along with the factors that might affect normal healing there is the possibility of risk
factors to influence the response of the skin when undergoing radiation therapy. Risk factors
that can affect skin healing during and after radiation therapy are related with the biological
status of each patient and with therapy parameters.
Keywords: scaring, healing process, impaired healing.
Introduction
Head and neck cancer patients need to undergo curative or paliation therapy. Since there is
a large variety of therapy available multiple choices are made only by consensus achieved in
the oncology committee. All available therapy, surgery, radiation therapy and chemotherapy,
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leave their signature at the site of the tumour and/or systemic. Surgery and radiation therapy
are more likely to leave marks at the site of the skin overlying the organ involved in the
cancer process. Radiation therapy is one of the most important methods of controlling head
and neck cancer and it can manifest with different complications at skin level, like dermatitis,
necrosis and even organ fistulas. Open surgery is, without a doubt, the most aesthetic
impairing method to treat cancer since incisions, scaring and wound complications are a
known possibility.
Wound healing after open surgery for head and neck cancer has a precise mechanism of
action that needs to be performed in a timely fashion, passing through all four stages of
evolution. However, since open surgery head and neck means that cavity organs of the upper
aero-digestive tract are being open, complications might occur in the healing process. The
most frequent complications of oral cavity, pharynx and larynx open surgery are wound
infection, haemorrhage and fistulas. Less frequent are vicious scaring and necrosis.
Wound healing needs to pass through haemostasis, inflammation, proliferation and
remodelling, since this is the normal pathway to effective scaring. Not only that all these
stages need to be completed but they need to occur in this particular order and need to last
accordingly.
Impaired healing of each wound is likely to occur if one or more factors disrupt the normal
time frame and evolution of one or more phases of the healing process. The most important
factors we need to take into account when dealing with a surgical patient are nutrition,
infection, diabetes, oxygen levels, alcohol and tobacco consumption, age and stress. There are
several other factors that might impeed with normal healing but we found that these are the
most common in our series of patients.
Along with the factors that might affect normal healing there is the possibility of risk
factors to influence the response of the skin when undergoing radiation therapy. Risk factors
that can affect skin healing during and after radiation therapy are related with the biological
status of each patient and with therapy parameters.
Radiation therapy risk factors
Several factors are known to impaire hed and neck cancer patients` skin while doing
radiation therapy. These factors had to be related to particular aspects of biological and
therapy alone standpoint. Therefore, these factors have been associated with patient
depending factors and therapy related factors. In regards to relative risk all these factors might
reside in increased risk for the patient to develop complications at skin level.
Patient related risk factors

Patient related risk factors have a variety of forms and all mut be analysed prior to the
beginning of therapy. First and foremost, we need to assess whether the patient had surgery
prior to radiation therapy. IN terms of skin integrity, we consider radiation therapy to begin at
least 6 to 8 weeks after surgery since this is the interval for which wound healing is complete
in all 4 stages. Neck skin is different from skin around the body to the extent that it is thiner,
has more folds due to high mobility area and is prone to friction [1]. Moreover, the amount of
fatty tissue underlying skin is to be considered since obesity is known to be the cause of
radiation therapy induced toxicity [2]. Wound healing is dependent on the quality of proteins
that help remake skin tissue and their synthesis can be influenced by the nutritional status,
age, exposure to sun and extreme temperatures [2]. Nutritional status is always evaluated
prior to surgery and up until 4 weeks after surgery. The tool most commonly used for this
evaluation is NRS 2002 which is a score that helps professionals evaluate the response of
food intake, macronutrients and beverage on the evolution of the healing process [3]. Some
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studies have established a link between race and ethnicity to the response subjects have to
radiation therapy and this should be considered in a multinationality cancer therapy center [4,
5].
Dermatological pathology is not to be ruled out when assessing such a patient especially if
the patient has signs of skin atopia, such as atopic eczema or psoriasus, or a bullous disease of
autoimmune origin. To this extent some clinical trials made a connection between
environmental factors (chemicals, solar radiation, heat/cold) and ionizing radiation to the
effect on sensitized skin of these patients [6-8]. Healing process uses connective tissue fibers
and inflammatory cells so a particular aspect is of patients with autoimmune or connective
tissue disease. Disease like scleroderma pigmentosum, sclerodermia, lupus erythematosis
predispose patients undergoing radiation therapy to dermatitis [9-11]. Some retrospective
studies indicate that patients with autoimmune disease express altered DNA in peripheral
lymphocites after radiation therapy [12, 13]. Reparation of altered DNA is subject to potential
risk in terms of severe complications after radiation therapy [14, 15]. Such potential
complications should be treated with great care by either reducing skin dose or by abandoning
radiation therapy. Several studies are trying to determine the connection between genetic
predisposition and radiation induced dermatitis so that prediction to radiation sensitivity is
optimal [16-18].
Oncology therapy risk factors

Surgical risk factors
Several risk factors can affect wound healing after major surgery. As previously discussed,
nutrition status needs to be evaluated prior to surgery and since as much as 60% of head and
neck cancer patients are malnourished or cachectic [19, 20]. Evaluation with different scores,
such as Patient-Generated Subjective Global Assessment (PG-SGA), Nutritional Risk
Screening 2002 (NRS 2002), Malnutrition Universal Screening Tool (MUST), Nutritional
Risk Index (NRI) and Malnutrition Screening Tool (MST), help reduce the risk in the peri-
operative period especially considering that surgery of the head and neck organs involve a
certain degree of malnutrition in the post-operative period [21, 22]. Stress and smoking
increase the chronic inflammation in soft tissues and might impair with wound healing.
If surgery is done prior to radiation therapy the presence of necrotic tissue, fistulas or
chronic wound infection are a major concern for skin related alterations. necrotic tissue is
subject to poor oxygenation of tissue and this usually occurs concerning a faulty surgical
technique, in elderly patients or in patients with skin modifications such as prior surgery with
previous scars, connective tissue disease or autoimmune disease. Necrotic tissue needs to be
excised into healthy tissue and only after 6-8 weeks of wound healing further oncology
therapy can be done for that region. Fistulas are communications between cavitary organs or a
cavity organ and skin.
Since the upper digestive tract is opened during open head and neck cancer surgery there is
the possibility of a fistula forming at this site. The characteristics of fistulas comprise
location, diameter and flow. Small fistulas are treated in a conservative manner, whereas high
output fistulas need to be surgically closed. By doing secondary revision surgery adjuvant
radiation therapy is going to be delayed which might affect prognosis. Appropriate technique,
suture materials need to be used when operating at pharynx site to prevent fistula formation.
However, fistulas can occur even with flawless technique due to impaired healing by host
risk factors, as detailed above.
Radiation therapy risk factors

Planning radiation therapy is out outmost importance since larger total skin dose, fraction
size of over 2 Gy, type (external beam therapy, brachytherapy) and amount of energy of
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radiation (IMRT, VMAT) as well as time of exposure are in direct relationship with skin
related adverse effects [23-25]. Skin toxicity is also present if photosensitizing concomitant
therapies are used to sensitize the tumour [26, 27]. Some photosensitizing drugs are activated
by UVA and UVB which can lead to subcutaneous tissue alterations [28].
Conclusions
Wound healing is of outmost importance while treating head and neck cancer patients due
to the potential interruptions of therapy. This delay in administering the whole therapy for
treatable tumours can influence the prognosis and the outcome of cancer therapy as a whole.
Even if the problem of pain, irritation, oedema, itching and even necrosis is well known
there are not enough meta-analysis to integrate data from different centers which treat head
and neck cancer patients. There is a large variation of therapy depending on each centers’
clinical experience. Health professionals need to reach a consensus in terms of solid
recommendations for reducing skin impairment after surgery and skin toxicity after radiation
therapy. Safety levels need to be set under the support of strong evidence from clinical trials.
Interesting possibilities arise from genetic research since predisposed patients to radiation
therapy sensitivity might be identified and tailored therapy strategy can be discussed.
Open surgery, especially after ardiation therapy, needs to take into account the possibility
of increased risk of complications and risk factors need to be identified and addressed.
Nutrition plays an important role in wound healing and correct assessment in the peri-
operative period can improve wound healing outcome. Tobacco and alcohol consumption, as
well as levels of oxygenation and stress play an important role in wound healing, therefor,
psychological support is in order. Some useful recommendations have been issued regarding
skin evaluation if risk factors are present. Most of them are included in good clinical practice,
some need further clinical trials to determine the optimal way to address this issue. Diabetes
and nutritional status are to be evaluated and controlled. If autoimmune or connective tissue
disease are in their acute phase, we must not initiate any type of cancer therapy. However, if
these types of disease are present, we need to further discuss therapy options in the oncology
committee with surgery being a better choice than radiation therapy. If radiation therapy is
considered adjustments of total dose, volumes and time of exposure need to be made. All skin
defects and pathology at the site of the oncology therapy needs to be assessed by a
dermatologist and proper follow-up is needed [29].
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induced acute or late effects. Radiother Oncol 2003; 69: pp. 155-60.
15. Iannuzzi CM, Atencio DP, Green S, Stock RG, Rosenstein BS. ATM mutations in female breast cancer
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16. Rattay T, Talbot CJ. Finding the genetic determinants of adverse reactions to radiotherapy. Clin Oncol
R Coll Radiol G B 2014; 26: pp. 301-8.
17. Mangoni M, Bisanzi S, Carozzi F, et al., Association between genetic polymorphisms in the XRCC1,
XRCC3, XPD, GSTM1, GSTT1, MSH2, MLH1, MSH3, and MGMT genes and radiosensitivity in
breast cancer patients. Int J Radiat Oncol Biol Phys 2011; 81: pp. 52-8.
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Implication of Cumarinic Overdosage in the ENT Sphere
PAVĂL Cristian Costel1, BERTEȘTEANU Ș.V.G.1,2, NIȚU Liliana1,2,

POPESCU B.1,2, OANCEA Alina1,2, SIMION-ANTONIE Catrinel Beatrice1,2,
BEJENARU Paula Luiza1,2, MUNTEANU Gloria Simona1,2,3,
CONDEESCU-COJOCĂRIȚA M.1,2, NICOLAESCU A.1,2,4, OTHMAN A.1,
POPA Teodora1, DIMCEA Alisa1, NEDELCU Ruxandra Ioana1,
DIACONU Teodora Elena1, TAHER Bianca Petra1, RUJAN Simona Andreea1,
SIREȚEANU Luiza Maria1, OAȘĂ Irina1, MITRAN Denisa1,
FLORESCU Elena1, ANDRONE Roxana1, VETRICEAN Iulia1,
DAYEH Iulia-Irena1, MIHALCEA C.C.1, TUDOSIE M.D.1, MAGDAN M.1,
CÎRSTEA A. I.1,2, ENEA A.G.1, COSTIN R.3, GRIGORE Raluca1,2
1 ENT, Head and neck surgery department, Coltea Clinical Hospital, Bucharest (ROMANIA)
2 “Carol Davila” University of Medicine and Pharmacy, Bucharest (ROMANIA)
3 ENT, Head and neck surgery department – “Carol Davila” Emergency Central Military Hospital, Bucharest (ROMANIA)
4 MAI Prof. Dr. Dimitrie Gerota Hospital, Bucharest (ROMANIA)
Abstract
Complications of treatment with oral anticoagulants in the ENT field require increased
attention and early recognition, as they have a varied impact on the patient, from a simple
episode of epistaxis to life-threatening upper airway hematomas. The aim of this study was to
identify the impact of coumarin anticoagulants on epistaxis and hematomas.
Discussion
Upper airway hematoma (UAH) secondary to warfarin therapy

is a rare but life-threatening condition. Hematomas have been
described in various places, including sublingual, retropharyngeal,
epiglottis and submaxillary. Although a sublingual hematoma can
be confused with infectious processes, such as Ludwig’s angina, it
is often evident on examination. However, the other hematomas
described may have more subtle signs until they compromise the
airways. [1] UAH can occur due to various exciting events,
including cervical spine injuries, neck surgery, rheumatoid arthritis, large vessel injuries and
violent movements of the head and in the case of patients treated with anticoagulant therapy.
[2, 3] UAH is a very serious event, but very rare. Therefore, the diagnosis and management of
this condition remains a challenge.
Warfarin acts as an antagonist of vitamin K by binding to vitamin K 2,3-epoxide reductase
in the liver microsome and blocking the action of vitamin K-dependent factors II, VII, IX, X,
protein C and protein S, commonly used for chronic anticoagulation in patients with atrial
fibrillation (AF), artificial heart valves and venous thromboembolism (VTE). Warfarin levels
are monitored with regular INR, with a target of 2 to 3 in AF and VTE and 2.5 to 3.5 in
patients with mechanical heart valves. Interaction with commonly used drugs, including
broad-spectrum antibiotics, quinidine, salicylate, and thyroxine, as well as alcohol and diet,
often make it difficult to anticoagulate with warfarin. [3] increasing the risk of bleeding. [3]
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Upper airway hematoma is a rare complication. Hematomas or sublingual,

retropharyngeal, epiglottis and submaxillary bleeding have been described. It is important to
recognize them early, as they can lead to life-threatening complications, such as airway
compromise.
UAH may be preceded by predisposing factors such as violent cough and trauma or may
be spontaneous. Sore throat, dysphagia and swelling of the throat are the most common
symptoms of UAH. These are nonspecific symptoms that can be associated with many
common clinical syndromes, such as acute respiratory tract infections. Differentiating from
the acute infectious process, such as Ludwig’s angina or retropharyngeal abscess, is crucial
because they are approached differently.
Patients with severe airway compromise should be considered a medical emergency and
endotracheal intubation may be indicated, as life-threatening bleeding may occur rapidly in
the sublingual space. [1]. The preferred treatment should be fiber-guided nasotracheal
intubation; cricothyroidism or aroused tracheotomy should be performed only in cases where
intubation is not possible and orotracheal intubation is contraindicated, as mask ventilation
may be impossible. [4]
Prophylactic antibiotics have been used in some cases; however, they are not usually
indicated because no abscess is formed. [1] Although steroids were used, there was no
definitive evidence of benefits. The patient may be restarted with warfarin with regular INR
monitoring once the hematoma resolves, provided that he can maintain an optimal INR level.
Conclusions
UAH is a rare but potentially serious complication of warfarin therapy, which should be
differentiated from the more common infectious etiologies. It is more common in the elderly
population with supratherapeutic INR and with some exciting events present in many cases.
In general, he has a good prognosis, with significant morbidity present only if a concomitant
respiratory compromise is present. Only mild cases should be observed, preferably in an
intensive care setting, and conservative treatment is possible in these patients, but no patient
characteristics predict successful airway compromise or successful conservative treatment.
The treatment of choice is the reversal of low-threshold anticoagulation for artificial
airway placement in the event of airway compromise.
REFERENCES
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https://doi.org/10.1007/s10103-019-02934-x.
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2714.170606.
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B-Cell Lymphoma of the Sinus Cavities – Case Report
POENARU Marioara1, MORAR Raluca1, BUGARI Radmila2,

CHIOREANU Alexandru2
1“Victor Babeș” University of Medicine and Pharmacy Timișoara (ROMANIA)
2“Vasile Goldis” Western University Arad, Otolaryngology department, Arad, Romania, (ROMANIA)
Emails: marioara.poenaru@gmail.com, ralu_morar@yahoo.com, radmilabugariturcin@gmail.com,
alexandru.chioreanu@yahoo.ro
Abstract
Lymphomas are solid cancers of the lymphatic system being classified into Hodgkin’s and
Non-Hodgkin’s. Among the Non-Hodgkin’s lymphomas there are B-cell lymphomas,
extranodal natural killer (NK)/T-cell lymphoma and other rare forms. Nasal and sinonasal
lymphomas are rare tumours, only about 1.5% being found in this regions(1). We present a
rare case of sinonasal lymphoma of a 62 years-old patient with periorbital cellulitis on the
right side.
Patient presented symptoms of sinusitis like headache and nasal obstruction for 3 weeks
but the cellulitis drove the patient to ask for medical help. An endoscopic biopsy was
performed revealing a b-cell Lymphoma. The patient was sent to oncology for further
treatment.
Keywords: b-cell Lymphoma, sinonasal cavities
Introduction
Hodgkin’s lymphoma tend to involve the lymph nodes meanwhile Non-Hodgkin’s are
more inclined to grow on mucosae and epidermis(2). That is why most of the time a
lymphoma found in the sinonasal cavities tend to have a bad prognosis. Meanwhile B-cell
Lymphomas are a form of Non-Hodgkin’s lymphoma that respond better to treatment in
comparison with extranodal natural Killer/T-cell. They might be found in the nasal mucosa,
on the nasal epidermis or in the sinus’s cavities. Symptoms found in the first stages of this
disease are similar to benign tumours and inflammations.
Case report
We present a case of a 62 years-old man, having a periorbital cellulitis alongside nasal
obstruction and intermittent headache. The symptoms time of debut varied, but the patient
came to an ENT specialist after he noticed a swelling under his right eye. Nasal endoscopy
revealed a septal deviation and no other signs of sinusitis. He received oral antibiotics, nasal
decongestant, and anti-inflammatories. 10 days after treatment the cellulitis disappeared, the
patient was feeling better so the treatment was stopped. He returned 2 weeks later with the
same periorbital cellulitis and has been sent to a cranial CT scan where the a right fronto-
ethmoidal sinusitis was observed.
An endoscopic sinus surgery was performed where a tumoral mass was present in the
frontal and ethmoidal cells. A biopsy was performed and sent to the histopathological exam.
The anatomo-pathological and immunohistochemical exam revealed a tumoral
proliferation with large cells, basophile cytoplasm, positive human leukocyte antigen, CD20,
CD79a, bcl6, bl2 and negative for cytokeratin AE1/AE3, Melan A, HMB45, CD10. Cell
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proliferation indicator was over 90%. In conclusion the diagnosis was B-cell Non-Hodgkin
lymphoma.
Patient was referred to oncology for further treatment.
Conclusion
Most common places for Lymphomas are the tonsils, Waldeyer’s ring, salivary glands (3,
4). Sinonasal cavities are easily overlooked and misdiagnosed as simple inflammatory
diseases (5, 6, 7). A patient having signs of sinusitis with relapses and no signs of infectious
or inflammatory disease in the nasal cavities should be a warning for the ENT specialist and
paraclinical exams such as a CT scan and a careful endoscopy should be mandatory (8).
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1. Wang MB. Sinonasal lymphoma: case series and review of the literature. 2014; 4(8): pp. 670-4.
2. Wang TYR. The diagnosis of sinonasal lymphoma: a challenge for rhinologists. 2012; pp. 1463-9.
3. Beasley MJ. Lymphoma of the Thyroid and Head and Neck Statement of Search Strategies Used and
Sources of Information Lymphoma of Waldeyer’s Ring. Clin Oncol [Internet]. 2012; 24(5): pp. 345-51.
Available from: http://dx.doi.org/10.1016/j.clon.2012.02.010
4. Pop DL, Nodiţi G, Abu-Awwad A, Maliţa DC, Zamfir CL, Grigoraş ML, Vermeşan D, Prejbeanu R,
Hărăguş HG, Boşcu AL, Ciupe BC, Deleanu BN, Faur CI, Folescu R. Alveolar rhabdomyosarcoma in
an adolescent male patient – case report and current perspectives. Rom J Morphol Embryol. 2018;
59(4): pp. 1247-1252. PMID: 30845308.
5. Balini G S, Borza C, Cristescu C, Andoni M, Simu G M, Malita D, Malita I, Cheveresan A,
Endogenous and Exogenous Antioxidant Protection for Endothelial Dysfunction, REVISTA DE
CHIMIE, Volume 62 Issue 6 Page 680-683 2011.
6. Licker M, Sorescu T, Rus M, et al., Extensively drug-resistant Myroides odoratimimus – a case series
of urinary tract infections in immunocompromised patients. Infect Drug Resist. 2018; 11: pp. 743-749.
Published 2018 May 18. doi:10.2147/IDR.S161069.
7. Horhat ID, Balica NC, Urechescu HC, Baderca F, Poenaru M, Doroş CI, Moţ IC, Boia ER, Mogoantă
CA, Chioreanu A, Vlăescu AN, Sarău CA. Rare benign tumor of the larynx – laryngeal amyloidosis.
Rom J Morphol Embryol. 2018; 59(4): pp. 1263-1268. PMID: 30845310.
8. Silviu Albu, Sorin Baschir, 2013 Intranasal phototherapy versus azelastine in the treatment of seasonal
allergic rhinitis, Auris Nasus Larynx, Volume 40, Issue 5, ISSN 0385-8146.
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Difference Between Open Surgery and TOUSS for Oropharyngeal

Cancer
POPESCU Bogdan1,2, OAȘă Irina Doinița1, BERTEȘTEANU Ș.V.G.1,2,

GRIGORE Raluca1,2, NIȚU Liliana1,2, MOȘOIU Anca1,2,
MITRAN Denisa Maria1, BEJENARU Paula Luiza1,2,
CONDEESCU-COJOCĂRIȚA M.1,2, NICOLAESCU A.2,4, FLORESCU Elena1,
CÎRSTEA Anca Ionela1, OTHMAN A.1, NEDELCU Ruxandra Ioana1,
DIACONU Teodora Elena1, TAHER Bianca Petra1,
RUJAN Simona-Andreea1, SIREȚEANU Luiza Maria1, ANDRONE Roxana1,
IRENA Dayeh1, DIMCEA Alisa1, VETRICEAN Iulia1, MIHALCEA C.C.1,
TUDOSIE Mihai1, MAGDAN Madalin1, PAVĂL Cristian1, ENEA Alexandru1,
OANCEA Alina Lavinia Antoaneta1,2
2 ENT, Head and neck department “Carol Davila” University of medicine and pharmacy, Bucharest, (ROMANIA)
3 ENT, Head and neck surgery department “Carol Davila” Emergency Central Military Hospital, Bucharest, (ROMANIA)
4 ENT, Head and neck surgery department MAI Prof. Dr. Dimitrie Gerota Hospital, Bucharest, (ROMANIA)
Email: irinaoasa@gmail.com
Abstract
The incidence of oropharyngeal cancer is directly linked to the consumption of tobacco,

alcohol and HPV. Each patient that has OPSCC needs to receive tailored oncological therapy.
All therapy options need to be discussed and optimal solution has to be expressed. Since
organ sparing is something that patients want curative or neoadjuvant chemo-radiotherapy are
widely taken into consideration. Several surgical techniques like transoral LASER surgery
(TLM) or trans oral robotic surgery (TORS) have been used to treat these patients. The time
span for these techniques is wide, TLM being introduced in 1990` and TORS in 2005. The
newer TOUSS technique is a hybrid method for surgically resolving OPSCC derived from
TORS. The advantages offered by TOUSS are mainly linked to the decreased invasiveness of
the surgical intervention by not performing complementary tracheostomy to this type of
surgery, by limiting the rejection – especially due to 4K zoom resolution capabilities –
appreciated by optic filter imaging NBI (narrow band imaging), by low thermal injury over
the adjacent tissue from rejection (thermic energy dissipation up to 2 mm from the resection)
and nonetheless, the lack of skin scars and overall drop of morbidity. TOUSS is a new
technique that is not yet included in cancer therapy guidelines but has some very strong
attributes. For stage I-III TOUSS seems to provide better exposure and outcome in trained
hands, especially concerning function preservation and aesthetic outcome.
Keywords: extended surgery indications, better quality of life, function preservation
Introduction
The incidence of oropharyngeal cancer is directly linked to the consumption of tobacco,

alcohol and HPV [1]. The direct correlation between smoking and oropharyngeal cancer
incidence is noted in a study performed in the United States which described the decreasing of
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upper aero-digetive squamous cell carcinoma (OPSCC) in direct correlation with the decrease
of tobacco consumption [2]. Moreover, the association with HPV infection is starting to be
more and more correlated with the occurrence of squamous cell carcinoma of the oral cavity
and pharynx since there was an increase of HPV-positive squamous cell carcinomas of the
oropharynx [3, 4]. This finding is not limited to the United States of America but is also
described in populations around the globe with as much as 70% HPV-positive OPSCC [5].
From the two major risk factors for oropharyngeal cancer the later is a better prognosis
disease since these HPV-positive tumours patients seem to have higher survival rates [6].
Each patient that has OPSCC needs to receive tailored oncological therapy. This is why the
standard for planning oncology therapy is represented by advisory opinion from the oncology
committee. Data like type of cancer, primary site, dimensions, loco-regional lymph node
metastasis, stage, biological status, morbidities and personal preferences need to be taken into
consideration [7]. All therapy options need to be discussed and optimal solution has to be
expressed. Since organ sparing is something that patients want curative or neoadjuvant
chemo-radiotherapy are widely taken into consideration. Several surgical techniques like
transoral LASER surgery (TLM) or trans oral robotic surgery (TORS) have been used to treat
these patients. The time span for these techniques is wide, TLM being introduced in 1990’
and TORS in 2005 [8, 9]. The newer TOUSS technique is a hybrid method for surgically
resolving OPSCC derived from TORS.
Surgical management options
Surgery is one of the therapy options for OPSCC patients disregarding the stage of the
disease. The main advantage of this approach is the possibility of total removal of the tumour
with safety margins analysis. The pTNM staging performed from the resection piece is
mandatory to evaluate the effectiveness of surgery and the overall status of the oncology
therapy management. If safety margins are clear to an optimal extent there is the possibility of
reducing the intensity of the adjuvant chemo-radiotherapy. This is benefical for the long-term
functional status of deglutition and speech as well as for the overall quality of life for these
patients [10].
Another important aspect to take into consideration is the level of expertise of the head and
neck cancer therapy center as well as the level of equipment. This is available for intensive
care expertise and equipment and also for follow-up capabilities. Surgical options are directly
dependant on the complex anatomy and vital and supravital functions of the pharynx. As a
general aspect surgery is possible by either open or transoral approach. Open approach is
mainly, but not limited to, pharynx approach via mandubulotomy or lateral pharyngotomy.
This type of approach is reserved for salvage surgery or locally advanced disease. even the
smaller tumours can be resected by this type of approach [11, 12]. Particular considerations of
the oncology committee should be considered for paliation techniques in patients with very
low chances of survival. Transoral techniques are capable of dealing with early-stage tumours
of the oropharynx and they include transoral surgical resection with cold or hot instruments
(monopolar cautery, bipolar cautery, radiofrecquency, coblation, TLM and TORS. More
recently, since 2014, a newer technique has been proposed for surgical removal by a transoral
approach of OPSCC. Transoral ultrasonic surgery (TOUSS) is a hybrid surgical technique
derived from TORS, using wide vision field by telescope and an ultrasonic bipolar scalpel.
Open techniques are related to increased morbidity with prolonged stay into the hospital
due to the need to perform a complementary tracheostomy, to place a nazo-gastric feeding
tube or gastrostomy, to perform a mandibulotomy with osteosynthesis. To this all patients add
aesthetic deformity and psychological impairments. In comparison to open techniques
disadvantages transoral approach confer particular advantages like preservation of anatomy
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structures (muscles, nerves), better function preservation with faster functional recovery,
reduced aesthetic outcome, better psychological profile, better quality of life and a shorter
stay into the hospital [13, 14]. Even if transoral approach is mainly used for limited early-
stage tumours, in selected cases this technique has been used to treat locally advanced
tumours [15].
Transoral ultrasonic surgery overview
TOUSS, coming from transoral ultrasonic surgery is a surgical technique introduced

worldwide in 2014 by M.M. Fernandez and it represents an alternative technique derived
from TORS (transoral robotic surgery). the development of this technique is based on already
existing technologies that were used in treating patients with malignant and benign tumour
pathology in the oral cavity, pharynx and larynx [16].
TOUSS has borrowed the auto static retractor from TORS technique along with the blades
that are mounted on the retractor for easy access end visualization of different regions of the
afore mentioned organs on which surgery can be performed from distance. in addition, image
enhancement and caption are performed with a 4K digital camera attached to a rigid telescope
fiber optics with flexible tip of 4 cm (OlympusTM Endoeye Flex 5mm/2D 10mm/3D) allow
widening the visual field of the rigid optic telescopes with 00 angulation (Olympus rigid 5 mm
2D) up to 1000. The telescope is mounted with the aid of a metallic arm with static joints for a
fixed position and widely use the surgical field according to the surgery necessities [16].
After mounting the auto static mouth retractor and the optical flexible telescope there is the
need for tissue manipulation instruments both for grasping tissue as well as for resection and
coagulation. For this we use the already known laparoscopic surgery forceps both for
dissection as well as for grasping tissue and resecting it. The instrument used for TOUSS
technique is a scalpel, also with known technology, is a combination of ultrasonic and bipolar
cautery, combined for cutting, coagulations and sealing vessels up to 7 millimeters in
diameter. This is called Thunderbeat TM and it is formed from a handle that controls the
functions, a long shaft of 35 cm that can facilitate telescopic manipulation of tissue and a tip
that combines the two technologies, ultrasonic and bipolar cautery, forming a single electro-
mechanic unit for cutting and cauterization [16].
Discussion
The advantages offered by TOUSS are mainly linked to the decreased invasiveness of the
surgical intervention by not performing complementary tracheostomy to this type of surgery,
by limiting the rejection – especially due to 4K zoom resolution capabilities – appreciated by
optic filter imaging NBI (narrow band imaging), by low thermal injury over the adjacent
tissue from rejection (thermic energy dissipation up to 2 mm from the resection) and
nonetheless, the lack of skin scars and overall drop of morbidity.
Disadvantages are linked to the means of manipulation – relatively long time for mounting
the auto static retractor and video camera, relatively steep learning curve, the lack of
describing the tumour by palpation and the acquisition cost.
All of this make from TOUSS an optimal approach for selected cases as an alternative for
TORS and classic LASER surgery. we must not neglect the fact that there are still no large
cohort studies to appreciate the oncology efficacy of surgery by TOUSS in comparison to
other surgical methods that are described and used in good clinical practice guides.
Discussion is ongoing regarding the two major risk factors for OPSCC, smoking and HPV.
HPV-positive tumours need to profit from a less invasive technique since patients with this
pathology have a profile that corresponds to young individuals with no smoking history and a
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better overall survival rate. In terms of function preservation this is the main category that
should benefit from transoral resection of OPSCC. Of course, indications are not limited to
this particular aspect and further data should be analysed to ensure proper indications for
transoral resection in smoking related OPSCC in stages III and IV. TORS is an expensive
method of oropharyngeal cancer therapy and, thus, unaccesible for most cancer therapy
centers. Some alternatives have potential benefits for both patients and surgeons, such as
TOUSS. However, clinical trials on function preservation are not yet available when
comparing transoral approach methods (TORS, LASER, TOUSS). Such data are of high
interest and should solve the matter of surgical indications regarding stage, age, morbidity and
recovery for selected cancer cases.
Some authors report encouraging data regarding deglutition at more than 1 year follow-up
after radical resection of OPSCC [17, 18].
Moreover, HPV-positive tumours benefit from TOUSS resection since narrow band
imaging is an important tool to assess vascular growth and extension of tumour in the
surrounding mucosa. This might be a game changer in terms of safety margins evaluation that
needs to be confirmed with on-site histopathological examination. The depth of field of
dissection and resection is yet to be optimal for TOUSS since there is no possibility of having
haptic feedback to resemble palpation which is of great help for the surgeon. Topographic
anatomy is of outmost importance when dissecting near great vessels of the neck and large
nerve trunk. In this case there is the possibility of adapting a Doppler echography probe to be
used during TOUSS procedure for better appreciation of relation to blood vessels. Even
though the use of Thunderbeat forceps that has the possibility of sealing blood vessels up to 5-
7 mm in diameter the risk of bleeding form larger blood vessels exists [19]. The extension of
indications for TOUSS should reside from improving topographical analysis.
Conclusions
TOUSS is a new technique that is not yet included in cancer therapy guidelines but has
some very strong attributes. The possibility of performing transoral surgery through an
enhanced view with 180-degree field of view which can be improved by repositioning the
telescope at the aid of a untrasonic advanced bipolar forceps is something that improves
precision of dissection, reduces bleeding at a point comparable with LASER surgery and
enhances functionality and quality of life. In comparison to LASER resection TOUSS has the
possibility of approaching advanced local disease in selected cases. Furthermore, surgical
indications can be extended to pathology that is usually approached with open techniques.
Further clinical trials will demosntrate this utility for TOUSS method. For stage I-III
TOUSS seems to provide better exposure and outcome in trained hands, especially
concerning function preservation and aesthetic outcome.
REFERENCES
1. Slaughter DP, Southwick HW, Smejkal W. Field cancerization in oral stratified squamous epithelium;
clinical implications of multicentric origin. Cancer. 1953; 6: pp. 963-968.
2. Carvalho AL, Nishimoto IN, Califano JA, et al., Trends in incidence and prognosis for head and neck
cancer in the United States: A site-specific analysis of the SEER database. Int J Cancer. 2005; 114: pp.
806-816.
3. Chaturvedi AK, Engels EA, Pfeiffer RM, et al., Human papillomavirus and rising oropharyngeal cancer
incidence in the United States. J Clin Oncol. 2011; 29: pp. 4294-4301.
4. Fakhry C, Westra WH, Li S, et al., Improved survival of patients with human papillomavirus-positive
head and neck squamous cell carcinoma in a prospective clinical trial. J Natl Cancer Inst. 2008; 100: pp.
261-269.
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5. Chaturvedi AK, Anderson WF, Lortet-Tieulent J, et al., Worldwide trends in incidence rates for oral
cavity and oropharyngeal cancers. J Clin Oncol. 2013; 31: pp. 4550-4559.
6. Deschler DG, Richmon JD, Khariwala SS, et al., The “new” head and neck cancer patient-young, non-
smoker, non-drinker, and HPV positive: evaluation. Otolaryngol Head Neck Surg. 2014; 151: pp. 375-
380.
7. Fakhry C, Zhang Q, Nguyen-Tan PF, et al., Human papillomavirus and overall survival after
progression of oropharyngeal squamous cell carcinoma. J Clin Oncol. 2014; 32: pp. 3365-3373.
8. Weinstein GS, O’malley BW Jr, Hockstein NG. Transoral robotic surgery: supraglottic laryngectomy in
a canine model. Laryngoscope. 2005 Jul; 115(7): pp. 1315-9.
9. McLeod IK, Melder PC. Da Vinci robot-assisted excision of a vallecular cyst: a case report. Ear Nose
Throat J. 2005 Mar; 84(3): pp. 170-2.
10. Francis DO, Weymuller EA, Jr, Parvathaneni U, et al., Dysphagia, stricture, and pneumonia in head and
neck cancer patients: Does treatment modality matter? Ann Otol Rhinol Laryngol. 2010; 119: pp. 391-
397.
11. Golusinski W. The role of conventional surgery in oropharyngeal cancer. Recent Results Cancer Res.
(2017) 206: pp. 185-95. 10.1007/978-3-319-43580-0_14.
12. Moncrieff M, Sandilla J, Clark J, Clifford A, Shannon K, Gao K, et al., Outcomes of Primary surgical
treatment of T1 and T2 carcinomas of the oropharynx. Laryngoscope. (2009) 119: pp. 307-11.
13. Tateya I, Shiotani A, Satou Y, Tomifuji M, Morita S, Muto M, et al., Transoral surgery for laryngo-
pharyngeal cancer – The paradigm shift of the head and cancer treatment. Auris Nasus Larynx. (2016)
43: pp. 21-32. 10.1016/j.anl.2015.06.013.
14. Arens C. Transoral treatment strategies for head and neck tumours. GMS Curr Top Otorhinolaryngol
Head Neck Surg. (2012)11: Doc05. 10.3205/cto000087.
15. Weinstein GS, O’Malley BW, Cohen MA, Quon H. Transoral robotic surgery for advanced
oropharyngeal carcinoma. Arch Otolaryngol Neck Surg. (2010) 136: 1079. 10.1001/archoto.2010.191.
16. Mario M. Fernandez-Fernandez, Lourdes Montes-Jovellar, Pablo Luis Parente Arias, Primitivo Ortega
del Alamo. TransOral endoscopic UltraSonic Surgery (TOUSS): a preliminary report of a novel
robotless alternative to TORS. Eur Arch Otorhinolaryngol. 2015; 272(12): pp. 3785-3791.
17. Hutcheson KA, Holsinger FC, Kupferman ME, et al., Functional outcomes after TORS for
oropharyngeal cancer: A systematic review. Eur Arch Otorhinolaryngal. 2015; 272: pp. 463-471.
18. Choby GW, Kim J, Ling DC, et al., Transoral robotic surgery alone for oropharyngeal cancer: Quality-
of-life outcomes. JAMA Otolaryngol Head Neck Surg. 2015; 141: pp. 499-504.
19. Seehofer D, Mogl M, Boas-Knoop S, Unger J, Schirmeier A, Chopra S et al., (2012) Safety and
efficacy of new integrated bipolar and ultrasonic scissors compared to conventional laparoscopic 5-mm
sealing and cutting instrument. Surg Endosc 26: pp. 2541-2549.
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Laryngeal Angioedema by Acquired C1 Inhibitor Esterase

Deficiency, Case Report
RĂDEANU Gheorghe Doinel1,2, BULMACI Mara1,2,

DINDELEGAN Maximilian George1,2, TĂNASE Mihai Ionuț1,2*,
STAN Constantin1,3*, MANIU Alma Aurelia1,2
1 Department of ENT, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, (ROMANIA)
2 Department of ENT, Emergency County Hospital, Cluj-Napoca, (ROMANIA)
3 Department of Surgical Clinical Dunărea de Jos University, Faculty of Medicine and Pharmacy, Galați, (ROMANIA)
* Corresponding authors: Tanase Mihai Ionut, Stan Constantin
Emails: doinel.radeanu@gmail.com, marabulmaci@gmail.com, maximilian.dindelegan@gmail.com,

dr.mihaitanae@gmail.com, stan.constantin90@yahoo.com, almacjro@yahoo.com
Abstract
C1 esterase inhibitor is a major inhibitor of activated factor XII, and inactivates plasmin,
factor XI, and kallikrein, and is the only inhibitor of the C1R and C1s complement. Thus, this
protein controls the level of C3 activation by preventing the formation of C3 convertase. The
deficiency of C1 esterase inhibitor leads to inappropriate activation of the C1 fraction and
subsequent release of C2, a peptide with kinin-like activity that increases vascular
permeability.
This deficiency is clinically transient with the occurrence of angioedema. The deficiency
of C1 inhibitor esterase occurs in two forms: hereditary and acquired, the acquired, presented
in this case, being a much less common variation. A 43-year-old patient is presenting urgently
in the Department of Otorhinolaryngology Cluj-Napoca for dysphagia for liquids and solids,
dysphonia, acute respiratory failure and edema of the larynx, informing the doctor about the
pathology she was known to have. After administration of two recombinant doses of the
human C1-esterase inhibitor, the symptoms regression occurs within a relatively short time of
about two hours, a re-assessment by local otorhinolaryngological examination where
remission of laryngeal edema is observed. The management of the present case in the clinic is
described in this article and other possible approaches to case management are offered.
Keywords: angioedema, C1 inhibitor esterase, laryngeal edema
Introduction
The deficiency of C1 esterase inhibitor (hereditary or acquired) is characterized by

subcutaneous or submucous edema in any part of the skin, respiratory tract or gastrointestinal
tract. In hereditary form, symptoms occur during childhood and are usually associated with
family history. The first mention in the literature about hereditary angioedema was made by
Cicardi, Fay and Abinun in 1963 [1]. The acquired form of the C1-inhibitor esterase is a rare
condition that occurs after the age of 40 years. It is caused by a lymphoproliferative disorder
and occurs as a result of the formation of autoantibodies to the anti-C1-inhibitor esterase. The
clinical picture consists of recurrent episodes of unruly edema without hives, occurring
spontaneously and unpredictably. Edema can lead to death by asphyxiation, so correct and
early diagnosis as well as proper treatment are essential.
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Genetics
The disease has autosomal dominant transmission with a spontaneous mutation rate of
25%, and over 100 genetic mutations related to C1 esterase inhibitor are known. Prevalence is
estimated at 1/50.000, with no connections within ethnic groups [2].
Fig. 1. C1 inhibitor function. Shaded bars indicate the inhibited stages of the complement and coagulation
pathways, kinin and fibrinolysis
PTA = plasma thromboplastin precursor [11]
Immunology
C1 inhibitor esterase is a protein with enzymatic activity of the serine protease group. It
inhibits the production of factor XIIa and kallikrein from the kinin-kallikrein system and
factor XIa of the kinin-kallikrein and coagulation system, thereby controlling the synthesis of
bradykinin, the major mediator of this form of angioedema. Bradykinin is a vasoactive
substance which, through bradykinin type 2 receptors in the endothelial cells, causes
vasodilatation and increased vascular permeability with interstitial fluid extravasation and
local edema formation. In the case of deficiency of C1 inhibitor esterase, its inhibitory role is
deficient, resulting in increased bradykinin synthesis and edema.
In the hereditary form, there is a genetic deficiency in the esterase inhibitor C1
synthesis/function, whereas in the obtained from the synthesis of the enzyme is normal, the
deficiency due to increased catabolism due to a lymphoproliferative disorder (B lymphocyte)
or of an autoimmune mechanism [3]. The acquired deficiency of C1 esterase inhibitor was
first described by Caldwell et al., in 1972. They presented a 49-year-old patient with
lymphosarcoma and C1 esterase inhibitor deficiency [4].
Fig. 2. Hypothetical initiation of an angioedema attack with deficient C1 esterase inhibitor.

The trauma activates the Hageman factor by forming plasmin, a C1 activator. (Frank M. M. et al.) [11]
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Case presentation
The 43-year-old woman, known for angioedema acquired by deficiency of C1 esterase
inhibitor since January 2018, is brought with the SMURD crew in the Emergency Department
of the County Emergency Clinical Hospital Cluj-Napoca accusing respiratory failure,
dysphagia, dysphonia and edema of the throat, debuted at about 12 AM. She is transferred in
the Otorhinolaryngology Department Cluj-Napoca to maintain her under supervision,
paraclinical investigations and specialized treatment.
The family medical history reveals a mother with history of hypertension and a father with
history of acute myocardial infarction, hypertension, type 2 diabetes and chronic grade 5 renal
failure. From the pathological personal history, we retain stage 2 essential hypertension,
mixed dyslipidaemia, cholecystectomy in 2018. In the anamnesis the patient is declared
smoker 3 packs a year, deny alcohol and coffee consumption or drug allergies or chronic drug
treatment except angiotensin-converting-enzyme inhibitors that was stopped some months
after angioedema onset. General clinical examination shows generally influenced state,
suffering facies and grade I obesity.
In the local otorhinolaryngological exam, facial erythema and mucosal congestion of the
laryngeal crown and pharynx is observed, mobile vocal cords and present respiratory space,
with the rest of the local exam in normal relations.
Following the administration of two ampoules of C1-inhibitor esterase inhibitor (1000 IU),
evolution was rapidly favourable with complete remission of symptomatology over a 4-hour
period. During the stay in the hospital the evolution was favourable, the patient being
discharged 48 hours after the presentation.
Diagnostic
Criteria requiring investigation of this deficiency are recurrent angioedema more than 24
hours between attacks, non-pruritic and non-responsive to antihistamines, serpentine rash,
recurrent colicky abdominal pain, familial history or low C4 supplementation.
Treatment
Treatment is divided into two branches: long-term prophylaxis and short-term prophylaxis.
Prolonged prophylaxis is done with attenuated androgens such as Danazol or Stanozol, or
with tranexamic acid. Short-term prophylaxis can also be used for acute attacks and is C1
inhibitor concentrate, attenuated androgens or high dose tranexamic acid. In both cases,
therapy is adjusted according to severity of symptomatology and individual response [5].
Discussions
Angioedema due to acquired C1 inhibitor esterase deficiency is a complex diagnosis,

generally established after many years of frequent attacks, with fluctuating and potentially
critical outcome, often attended by lymphoproliferative disease.
The statistics regarding adult-onset non-allergic angioedema in medical activity is
frequently close to angiotensin-converting-enzyme inhibitors induced forms and the complex
fundamental process of the disease are poorly constructive.
Reports from the literature observe 58% patients with recurring onset within 3 months and
41% over the 1st month after angiotensin-converting-enzyme inhibitors discontinuance,
consequently, interchange diagnosis might be considered if no important clinical
improvement is seen after 1-3 months. [6, 7]
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Acute onset of acquired angioedema were mostly localized to the face and abdomen and
half of the patients suffered potentially life-threatening crisis due to laryngeal or tongue
localization. [8]
Cure of C1 inhibitor esterase – acquired angioedema should take into account the
fundamental disease likewise the frequency and gravity of angioedema. The current standards
for treatment of acquired angioedema recommends plasma derived C1 inhibitor esterase,
bradykinin B2 antagonist and kallikrein inhibitor, while antifibrinolytic agents such as
tranexamic acid and attenuated androgens are indicated for long-term acquired angioedema
prophylaxis. [9]
Long-term prevention of acquired angioedema can be done with attenuated androgens or
antifibrinolytic agents such as tranexamic acid, which is considered by some authors as the
drug of election for C1 inhibitor esterase-acquired angioedema. [10]
Conclusions
The diagnosis, long term medication and follow-up may be challenging and should take
into consideration experts’ opinion and guidelines recommendations.
In this case, the key element was the information received from the patient, who knew the
disease, thus specific measures were applied, with an efficient and rapid recovery. Laryngeal
edema has features characteristic for an allergy, but antihistamine administration is
completely ineffective in these cases, thus presenting a major risk. The next step is the
administration of corticosteroids, with a satisfactory effect but with a more difficult recovery
and multiple undesirable side effects. The patient concerned, before being diagnosed with
deficiency of the C1 inhibitor acquired hepatic enzyme, followed several long-term
corticosteroid treatment cycles that he discontinued due to severe side effects, including
obesity, hypertension, dyslipidemia, and condition generally altered. It is important that these
cases to be recognized early and treated appropriately, as they can greatly limit patient
morbidity and the impact of the pathology they experience. In these cases, at the time of
suspicion, after prior hemodynamic and respiratory stabilization, it is advisable to redirect the
patient to the allergy and immunology service for further investigation.
REFERENCES
1. Cicardi M, Bergamaschini L, Marasini B, Boccassini G, Tucci A, Agostoni A. (1982). Hereditary

angioedema: an appraisal of 104 cases. Am J Med Sci.
2. Kleiner GI, Giclas P, Stadtmauer G, Cunningham-Rundles C. (2001). Unmasking of acquired
autoimmune C1-inhibitor deficiency by an angiotensin-converting enzyme inhibitor. Ann Allergy
Asthma Immunol.
3. Tosi M. (1998). Molecular genetics of C-inhibitor. Immunobiology.
4. Agostoni A, Aygoren-Pursun E, Binkley KE et al., (2004). Hereditary and acquired angioedema:
problems and progress: proceedings of the third C1 esterase inhibitor deficiency workshop and beyond.
J Allergy Clin Immunol.
5. Bork K, Witzke G. (1989). Long-term prophylaxis with C1-inhibitor (C1 INH) concentrate in patients
with recurrent angioedema caused by hereditary and acquired C1-inhibitor deficiency. J Allergy Clin
Immunol.
6. Watson RD, Gershwin ME. (2000). Acquired angioedema associated with sinusitis. J Invest Allergol
Clin Immunol.
7. Faisant C, Armengol G, Bouillet L, Boccon-Gibod I, Villier C, et al., Angioedema triggered by
medication blocking the renin/angiotensin system: retrospective study using the French National
Pharmacovigilance Database. J Clin Immunol. 2016; 36: pp. 95-102.
8. Sheffer AL, Austen KF, Rosen FS, Fearon DT. Acquired deficiency of the inhibitor of the first
component of complement: report of five additional cases with complementary on the syndrome. J
Allergy Clin Immunol. 1985; 75: pp. 640-6.
9. Cicardi M, Zanichelli A. Acquired angioedema. Allergy Asthma Clin Immunol. 2010; 6: p. 14.
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10. Agostoni A, Aygoren-Pursun E, Binkley KE, Blanch A, Bork K, Bouillet L, et al., Hereditary and
acquired angioedema: problems and progress: proceedings of the third C1 esterase inhibitor deficiency
workshop and beyond. J Allergy Clin Immunol. 2004; 114(Suppl3): pp. S51-131.
11. Frank, M.M. Hereditary angioedema: the clinical syndrome and its management in the United States.
Immunol Allergy Clin North Am. 2006; 26: pp. 653-668.
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Surgical Reconstruction Methods for Head and Neck Skin Defects

after Oncological Surgery
RUJAN Simona-Andreea1, GRIGORE Raluca1,2, NIȚU Liliana1,2,

POPESCU Bogdan1,2, OANCEA Alina Lavinia1,2, MOȘOIU Anca1,2,
TEODORESCU-ARGHEZI Ertan1, SIMION-ANTONIE Catrinel Beatrice1,2,
BEJENARU Paula Luiza1,2, CONDEESCU-COJOCĂRIȚA Mihnea Florin1,2,
NICOLAESCU Alexandru2,4, MUNTEANU Simona-Gloria1,2,3,
CÎRSTEA Anca Ionela1, TAHER Bianca-Petra1, SIREȚEANU Luiza-Maria1,
MITRAN Denisa Maria1, OAȘĂ Irina Doinița1, FLORESCU Elena1,
ANDRONE Roxana1, DIMCEA Alisa1, NEDELCU Ruxandra Ioana1,
DIACONU Teodora Elena1, OTHMAN Amer1, VETRICEAN Iulia1,
MIHALCEA Cătalin-Constantin1, TUDOSIE Mihai1, MAGDAN Mădalin1,
PAVĂL Crtistian-Costel1, COSTIN Romeo3, ENEA Alexandru-Gabriel1,
BERTEȘTEANU Șerban-Vifor-Gabriel1,2
1 ENT Department, Coltea Clinical Hospital, Bucharest, (ROMANIA)
2 ENT Department – “Carol Davila” University of Medicine and Pharmacy, Bucharest, (ROMANIA)
3 Central Military Emergency Hospital “Carol Davila”, Bucharest, (ROMANIA)
4 Dr. Professor Dimitrie Gerota Emergency Hospital, Bucharest, (ROMANIA)
Email: simonaar28@yahoo.com
Abstract
Introduction
Skin cancers in the cephalic extremity have an increasing incidence due to chronic sun
exposure and can be divided in two major categories: non-melanomic and melanomic.
However, the mortality rate remained relatively stable. The main types of non-melanomic
cancers are basal cell carcinoma and squamous cell carcinoma. Although the ideal adjuvant
therapy has not been found, there are many therapeutic options that allow both a high
curability rate and very good functional and aesthetic results. Sun protection and an early
assessment of suspicious areas remain the first line of defence against skin cancer.
Methods
The following study presents a retrospective analysis of 3 clinical cases diagnosed in the
Coltea ENT Clinical Hospital with skin cancer of the cervico-facial region, which highlights
the therapeutic aspects and postoperative results of various surgical methods of reconstruction
of cervico-facial skin defects after oncological surgery.
Results
The selected cases include 3 different histopathological forms of skin cancer: malignant
cheek melanoma, nasal wing basal cell carcinoma and squamous cell carcinoma of the lower
lip. In the case of malignant melanoma, the free skin graft was used as a method of
reconstruction; in the case of squamous cell carcinoma, a slipped submandibular
musculocutaneous flap was used and for the basal cell carcinoma, the reconstruction of the
nasal wing defect was accomplished by using ear cartilage completed with rotated nasolabial
flap.
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Conclusions
Therapeutic methods may be influenced by various factors, including age, comorbidities of
the patient and location of the lesion. The reconstruction method of the cervicofacial region is
important both from an oncological and an aesthetic point of view.
Keywords: reconstruction methods, head and neck, skin defects
Introduction
Skin cancer is the most common type of cancer among the caucasian population. At the
level of the cephalic extremity, skin cancer has an increasing incidence due to chronic sun
exposure, but the mortality rate has remained relatively stable. The main types of skin cancer
are: melanomic and non-melanomic cancers. Regarding the second category, the non-
melanomic ones are also divided into two main categories: basal cell carcinoma (BCC) and
squamous cell carcinoma (SCC). BCC and SCC fall into the group of epithelial skin cancers,
but there is also a lower percentage of non-melanoma cancers – non-epithelial skin cancers,
which develop from neuroendocrine cells, mesenchymal or vascular structures (Merkel cell
carcinoma, dermatofibrosarcoma protuberance, atypical fibroxanthoma, sebaceous carcinoma,
carcinoma of the adnexal glands). Melanomic cancers differ from non-melanomic cancers in
that they are less common, but the mortality rate is much higher compared to non-melanomic
cancers, which have a faster evolution and untreated become locally and functionally
destructive. For example, in the United States, more than 1 million cases of non-melanoma
cancers are diagnosed, compared to melanoma, which accounts for 5% of all cancers
diagnosed annually, 15% of which are fatal [1], [2].
At the moment there is no ideal adjuvant therapy, but various therapeutic options are
described that allow a high cure rate, as well as very good functional and aesthetic results.
Due to the occurrence of skin cancers with an increased incidence in areas with chronic
sun exposure, early assessment of suspicious areas and sun protection remain the first line of
defense against skin cancer.
Methods
The following study presents a retrospective analysis of 3 clinical cases diagnosed in the
Coltea ENT Clinical Hospital with skin cancer of head and neck, which highlights the
therapeutic aspects and postoperative results of various surgical methods of reconstruction of
cervico-facial skin defects after oncological surgery.
Results
Case 1
A 61-year-old patient, known with lower lip neoplasm (histopathological examination –
squamous cell carcinoma) operated and treated in 2019, aorto-bifemural bypass, essential
hypertension, presented to the ENT Clinic of the Colțea Clinical Hospital for the reappearance
of a tumour in the lower lip, for about 4 months ago. It was decided to be hospitalized for
investigations and specialized surgical treatment. The local clinical examination describes a
tumour of the lower lip, ulcerated, about 2/3 cm, painful spontaneously and on palpation.
Under general anaesthesia and orotracheal intubation, ablation of the lower lip tumour
formation (Fig. 1), right functional neck dissection, right sub-maxillectomy is performed.
Reconstruction with slipped submandibular muscle-skin flap (Fig. 2, 3, 4).
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Fig. 1. Fig. 2. Fig. 3. Fig. 4.

Fig. 1. Intraoperative aspect of the post excisional defect
Fig. 2-4. Intraoperative aspect of the slipped submandibular flap
Follow-up: At 2 months post-surgery, the local evolution of the patient is favourable. No

signs of local recurrence. (Fig. 4,5)
Fig. 4,5. Two-month postoperative aspect
Case 2
The second case is a 77-year-old female patient. Among the personal pathological history,
we mention essential hypertension under treatment, arterial fibrillation, NYHA class II heart
failure, Parkinson’s disease. The patient presented to our Clinic for the appearance of two
tumours on the right cheek for about 2 years, with progressive growth (Fig. 1,2), accelerated
recently and bleeding from them (Fig. 3). At the clinical examination, have been described on
the right cheek two round-oval tumours of approximately 2/3 cm, respectively 1.5/1 cm, firm
consistency.
Fig. 1. Fig. 2. Fig. 3.

Fig. 1,2,3. Progressive evolution of the cheek tumours in the last two years
Under general anaesthesia and orotracheal intubation, is performed ablation of the right
cheek tumour (Fig. 4) (extemporaneous histopathological examination: malignant melanoma-
confirmation at paraffin), right functional neck dissection (Fig. 5), free skin graft harvesting
from the arm (Fig. 5,6), reconstruction of the right cheek defect with free skin graft (Fig. 7).
Compressive bandage (Fig. 8).
Fig. 4. Intraoperative aspect of the post excisional defect Fig. 5. Functional neck dissection
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Fig. 5,6. Free skin graft harvesting from the arm
Fig. 7,8. Reconstruction of the right cheek defect with free skin graft and compressive bandage
Follow-up: the quality of life is much increased; the patient’s evolution is favourable. No
signs of recurrence so far. Following the evaluation of the case by the oncology commission,
it was decided that the treatment should be only surgical, with regular follow-up of the
patient.
Fig. 9. Eight-month postoperative aspect
Case 3
Female pacient, 51-year-old known with: left nasal ala neoplasm (histopathological
examination: basal cell carcinoma); essential hypertension, ischemic stroke, type II diabetes,
presented in the Coltea ENT Clinic for appearance of a tumour at the left nasal ala for about 6
months, which has progressively increased in size. At the local clinical examination, an
ulcerated tumour was described at the level of the left nasal ala of approximately 1.5/2 cm.
(Fig. 1)
Under general anaesthesia and orotracheal intubation the ablation of the tumour formation
from the left nasal ala is performed (Fig. 2). Reconstruction of the left nasal ala defect with
auricular cartilage and nasolabial flap is performed. (Fig. 3,4,5)
Fig. 1. Preoperative aspect of the tumour Fig. 2. Intraoperative aspect of the post excisional defect
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Fig. 3,4,5. Reconstruction of the defect with auricular cartilage and nasolabial flap
Discussion
Basal cell carcinoma is the most common type of cancer. In 2000, it was estimated at the
American Cancer Society that 75% of all skin cancers were represented by basal cell
carcinoma, and later in 2008 more than 1 million new cases were estimated. [2] Although this
type of cancer does not have a high mortality rate and is more aggressive locally than
systemically, cases associated with bone or nervous system metastases have been reported. [3]
Squamous cell carcinoma is the second most common type of cancer in the United States,
but with a higher mortality rate than basal cell carcinoma. The American Cancer Society
estimates in 2000 that at least 20% of all skin cancers were due to squamous cell carcinoma.
[2] Both sun exposure and genetic predisposition are involved in the pathogenic mechanism
of squamous cell carcinoma. The changes that UV rays produce on the DNA of keratinocytes
are the most important carcinogenic factor, as 80% of squamous cell carcinomas occur in
areas with chronic sun exposure. It seems that UVB rays have a more important role in this
regard.
The most commonly used treatment method for the treatment of non-melanomic skin
cancer is surgery, with the excision of the tumour within the limits of oncological safety.
The American Cancer Society has estimated over 62,000 new cases diagnosed with
melanoma.[2] Although most melanomas are pigmented lesions, there are still less than 2% of
amelanic melanomas, which often pose diagnostic problems. [4]
Surgical excision is the standard of treatment for all primary melanomas. Although for
decades the excision of tumour with 5 cm safety margins in all directions has been considered
the standard, a recent meta-analysis shows that there would be no significant differences in
mortality if we compare broad excision with limited margin excision. [5], [6]
According to the World Health Organization and some Australian and European trials,
adequate 1 cm safety margins are accepted for melanomas <1 mm. The excision margin for
melanomas between 1-4 mm is recommended to be 2 cm. [7]
Conclusions
The method of reconstruction of the cervicofacial region is important both from an

oncological and aesthetic point of view. The therapeutic decision can be influenced by various
factors, including age, comorbidities of the patient and the location of the lesion.
REFERENCES
1. Miller DL, Weinstock MA. Nonmelanoma skin cancer in the United States: incidence. J Am Acad
Dermatol 1994; 30: pp. 774-8.
2. American Cancer Society, 2008 statistics. Available at:
http://www.cancer.org/downloads/STT/2008CAFFfinalsecured.pdf. Accessed June 10, 2009)
3. Elghissassi I, Mikou A, Inrhaoun H, et al., Metastatic basal cell carcinoma to the bone and bone
marrow. Int J Dermatol 2009; 48(5): pp. 48-3.
4. Giuliano AE, Cochran AJ, Morton DL. Melanoma from unknown primary site and amelanotic
melanoma. Semin Oncol 1982; 9(4): pp. 442-7.
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737890/
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D.; Grigore, R.; Safta, D.; et al., HIPPOKRATIA Volume: 18 Issue: 2 Pages: 120-124 Published: 2014
7. Lens MB, Nathan P, Bataille V. Excision margins for primary cutaneous melanoma: updated pooled
analysis of randomized controlled trials. Arch Surg. 2007; 142(9): pp. 885-91.
https://doi.org/10.3892/etm.2019.7857.
doi: 10.3892/etm.2019.7635. Epub 2019 May 31.
2016, Vol. 1 (20), pp. 380-383.
https://doi.org/10.1155/2020/3526316.
https://doi.org/10.1007/s10103-019-02934-x.
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Hearing Impairment in Patients with Cholesteatoma
ȘERBAN Roxana2, BUTNARU Corina1,2, MERIACRE Tatiana1,2, MÂRȚU Dan1,

RĂDULESCU Luminița1,2
1University of Medicine and Pharmacy “Grigore T. Popa” Iași – Department of Otorhinolaryngology (ROMANIA)
2Clinical Rehabilitation Hospital, Iasi – ENT Clinic (ROMANIA)
Emails: cmbutnaru@yahoo.com, roxana_serban10@yahoo.com
Abstract
Introduction
Chronic otitis media with or without cholesteatoma is characterized by mixed or
transmission hearing loss of varying degrees, depending on the level of damage to the middle
ear and cholesteatoma extension.
Material and method

The study was a prospective one, performed on a group of 34 patients with cholesteatoma,
hospitalized in the Clinical Rehabilitation Hospital, ENT Clinic from Iasi. All patients had an
audiogram before surgery. Other data collected were: demographic data, intraoperative
findings, surgical techniques performed.
Results and discussions

On the studied cases, the degree of hearing loss varied from 26 dB to 120 dB, registering
an average level of 56.48±19.41 dB, which highlights a medium degree of hearing loss,
without significant differences between the sexes (58.07 vs 55.22; p=0.612), age groups
(56.56 vs 56.39; p=0.976), place of origin (57.78 vs 54.95; p=0.612) and educational level
(p=0.653). The statistical analysis of the values showed that the average level of air
conduction increased significantly with increasing frequency from 0.5 KHz to 4 KHz (54.20
vs 62.0; p=0.003). Also, the average level of bone conduction increased significantly with
increasing frequency from 0.5 KHz to 4 KHz (18.20 vs 26.60; p=0.001). Air-Bone Gap
(ABG) calculated at a frequency of 0.5 KHz varied widely (36.74%) from 10 dB to 60 dB,
averaging 36.0±11.69 dB. The lowest value of ABG was recorded on the frequency of 2 KHz,
with an average of 28.30 dB, with a standard deviation of 11.41 dB.
Conclusions
ABG varied on the studied group in restricted intervals. Ossicular erosion contributes to
the increase of ABG.
Keywords: cholesteatoma, air bone gap, audiometry
Introduction
In chronic suppurative otitis media with or without cholesteatoma local inflammation plays
an important role in development, maintenance and progression of the disease. Inflammation
from the middle ear can be associated with pathological values of nitric oxid (involved in
leukocyte adhesion, proliferation and cytokine expression) [1], angiogenic factors,
interleukin-1, interleukin-6, interleukin-17, interferon-beta, and parathyroid-hormone-related
proteins, matrix-metalloproteinases, and antioxidant factors [2, 3].
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The use of oral bisphosphonates is associated with an increased risk of cholesteatoma of

the external auditory canal or osteonecrosis of the ear canal [4, 5]. Bisphosphonate efficacy is
conferred by its chemical properties by absorbing hydroxyapatite and then inhibiting the
hydroxyapatite destruction [6].
The air-bone gap (ABG) represents the difference between air conduction (AC) and bone
conduction (BC) audiometric thresholds. ABG are found in outer and/or middle ear diseases
such as external otitis, interruption or fixation of the ossicular chain and different types of
chronic otitis media. Sometimes, an ABG can be found in the inner ear diseases due to a third
window mechanism or in endolymphatic hydrops [7].
In cholesteatoma the ABG shows the ossicle chain injury and may be predictive factor for
disease extension. Also, it is known that the tissue formed in the middle ear can transmit
sounds replacing the affected ossicles, therefore the audiometry does not always show the real
state of the ear transmission system [8]. Knowing the status of the ear crucially important for
surgery, in association with CT scan. The goal of surgery is to remove the pathological tissue,
and to preserve or improve hearing by ossiculoplasty [9, 10, 11].
Material and method
The prospective study was performed on a group of 34 patients with cholesteatoma,

hospitalized in the Clinical Rehabilitation Hospital, ENT Clinic from Iasi. Each patient
underwent pure tone audiometry before surgery.
The inclusion criteria in this study were represented by: imaging and clinical diagnosis of
cholesteatoma.
Other data collected were: demographic data, intraoperative findings and the surgical
technique performed.
The data obtained were processed in an SPSS database version 18.0 (SPSS, Inc) and
processed with specific statistical functions, at the significance threshold of 95%.
The ANOVA test was used to evaluate descriptive statistical indicators: minimum,
maximum, mean, median, standard deviation, standard error of the mean, variance.
Results and discussions
The AC measured at a frequency of 0,5 KHz ranged between 25dB and 120dB, recording a
mean level of 54.20±20.21 dB. The highest mean value was recorded at 4 KHz and the lowest
at 2 KHz (Table I). The tests of normality in frequentist statistics, Skewness and Kurtosis (-
2<P<2), were used to evaluate the distribution of continuous variables.
Table I. Descriptive statistics of AC values (dB) in patients with cholesteatoma

AC 0.5 KHz AC 1 KHz AC 2 Kz AC 4 KHz
Mean 54.20 56.90 52.80 62.00
Median 52.50 55.00 52.50 60.00
Standard deviation 20.21 22.01 19.90 23.32
Variance 37.29 38.68 37.69 37.61
Skewness test 0.932 0.760 0.845 0.522
Er. Std. Skewness 0.337 0.337 0.337 0.337
Minimum 25 25 20 25
Maximum 120 120 120 120
Percentiles 25 40.00 40.00 40.00 45.00
50 52.50 55.00 52.50 60.00
75 66.25 71.25 61.25 75.00
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Since the mean values were close to the median and the Skewness test result was under
two, regardless of the frequency at which the determinations were made, this suggests that the
series of values of this parameter were homogeneous.
The mean level of AC increased significantly with increasing frequency from 0.5 KHz at 4
KHz (54.20 dB vs 62.0 dB; p=0.003) (Fig. 1).
Fig. 1. Mean values of AC (dB) in patients with cholesteatoma

depending on the frequency
Bone conduction measured at a frequency of 0.5 KHz varied widely (83.40%) from 0 to
75, recording an average level of 18.20±15.18 KHz. The highest value was recorded on 4
KHz, respectively 26,60±18.22 (Table II).
Table II. Descriptive statistics of BC values (dB) in patients with cholesteatoma

BC 0.5 KHz BC1KHz BC 2 KHz BC 4 KHz
Mean 18.20 22.20 24.50 26.60
Median 15.00 20.00 20.00 20.00
Standard Deviation 15.18 16.76 15.88 18.22
Variance 83.40 75.50 64.82 68.50
Skewness test 1.470 0.972 0.815 0.686
Er. Std. Skewness 0.337 0.337 0.337 0.337
Minimum 0 0 0 0
Maximum 65 70 75 75
Percentiles 25 10.00 10.00 13.75 15.00
50 15.00 20.00 20.00 20.00
75 25.00 31.25 35.00 36.25
The mean values close to the median values and the result of the Skewness test <2,
regardless of the frequency at which the determinations were made, suggest that the series of
values of this parameter were homogeneous.
The average level of bone conduction increased significantly with increasing frequency
from 0.5 KHz to 4 KHz (18.20 vs 26.60; p=0.001) (Fig. 2).
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Fig. 2. Mean values of BC (dB) in patients with cholesteatoma

depending on the frequency
ABG calculated at a frequency of 0.5 KHz varied widely (36.74%) from 10 to 60,
registering a mean level of 36.0±11.69 KHz (Table III).
The mean values close to the median values and the test result -2< Skewness <2, regardless
of the frequency at which the determinations were made, suggest that the series of values of
this parameter were homogeneous.
Table III. Descriptive statistics of ABG values (dB) in patients with cholesteatoma
ABG 0.5 KHz ABG 1 KHz ABG 2 KHz ABG 4 KHz
Mean 36.00 34.70 28.30 35.40
Median 35.00 35.00 27.50 35.00
Standard Deviation 11.69 10.99 11.41 12.20
Variance 36.74 20.83 30.21 48.82
Skewness test -0.022 0.211 0.117 0.281
Er. Std. Skewness 0.337 0.337 0.337 0.337
Minimum 10 15 0 10
Maximum 60 55 60 60
Percentiles 25 25.00 28.75 20.00 25.00
50 35.00 35.00 27.50 35.00
75 45.00 40.00 35.00 45.00
The mean level of bone conduction decreased slightly with increasing frequency from 0.5
KHz to 4 KHz (36 vs. 35.40; p=0.736) (Fig 3).
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Fig. 3. Mean values of ABG (dB) in patients with cholesteatoma depending on the frequency
Analysing the osscilar chain lesions we found that in 62% of cases the malleus was lysed,
in 22% it was intact and in 16% it was absent. The incus was eroded in 74% of cases, and in
18% it was absent. The stapes was eroded in 48% of cases, and in 62% it was intact.
Albera et al., found that ossicular lesions are not related to age, cholesteatoma localization
or the presence of otorrhea. In his study AC varied between 48 and 71 dB and BC between 18
and 39 dB with ABG between 25 and 32 dB (9). Our study found the ABG in the same
interval (mean value varied from 28,3 to 36 dB). Martins at al., found limited information
about the relationship between ossicular destruction and ABG in patients with cholesteatoma
in a study performed between 1992 and 2009 (12). Jeng FC et al., in his study made on 190
patients explain that the ABG value was not correlated with ossicular discontinuity (13) but
Carillo et al., suggest that a narrow ABG at lower frequencies suggested absence of ossicular
discontinuity (14).
In one recent study conducted on 107 ears with chronic suppurative otitis media, Bayat et
al., sustain that the ABG and pure tone audiometry values cannot be considered a predictor
factor for ossicular chain status (15).
In the most recent study about chronic otitis media conducted on 72 ears found a mean
preoperative ABG of 34.63dB (16). In our study the mean value in patients with
cholesteatoma was 33,6 dB.
Conclusions
The ABG is a parameter that had relatively small interval variances. Ossicular chain
lesions contribute to a hearing level decline.
REFERENCES
1. Buca, B.R., Tartau, L.M., Rezus, C., et al., (2018). The Effects of Two Nitric Oxide Donors in Acute
Inflammation in Rats Experimental data. Revista de Chimie 69(10), pp. 2899-2903.
2. Kuo, C.L., Shiao, A.S., Yung M., et al., (2015). Updates and knowledge gaps in cholesteatoma
research. Biomed Research International p. 854024.
3. Teodor, V., Cuciureanu, M., Filip, C., et al., (2011). Protective effects of selenium on acrylamide
toxicity in the liver of the rat. Effects on the oxidative stress. Revista Medico-chirurgicala a Societatii
de Medici si Naturalisti din Iasi 115(2), pp. 612-618.
4. Thorsteinsson, A.L., Vestergaard, P., Eiken, P. (2014). External auditory canal and middle ear
cholesteatoma and osteonecrosis in bisphosphonate-treated osteoporosis patients: a Danish national
register-based cohort study and literature review. Osteoporosis International 25(7), pp. 1937-44.
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5. McCadden, L., Leonard, C.G., Primrose, W.J. (2018). Bisphosphonate-induced osteonecrosis of the ear
canal: our experience and a review of the literature. The Journal of Otology and Laryngology 132(4),
pp. 372-374.
6. Filip, A., Veliceasa, B., Puha, B., et al., (2019). Bisphosphonates Influence and Pain Assessment in
Mobilization of Patients with Fragility Fracture of the Pelvis, Revista de Chimie 70 (3), pp. 1094-1097.
7. Scarpa, A., Ralli, M., Cassandro, C., et al., (2020). Inner-Ear Disorders Presenting with Air-Bone Gaps:
A Review. The Journal of Advanced Otology 16(1), pp. 111-116.
8. Jung, M.H., Lee, J.H., Cho J.G. (2018). Expressions of caspase – 14 in human middle ear
cholesteatoma. Laryngoscope 118, pp. 1047-1050.
9. Albera, R., Canale, A., Piumetto, E., et al., (2012). Ossicular chain lesions in cholesteatoma. Acta
Otorhinolaryngologica Italica 32(5), pp. 309-313.
10. Martins, O., Victor, J., Selesnick, S. (2012). The relationship between individual ossicular status and
conductive hearing loss in cholesteatoma. Otology and Neurotology 33(3), pp. 387-92.
11. Maresh, A., Martins, O.F., Victor, J.D., et al., (2011). Using surgical observations of ossicular erosion
patterns to characterize cholesteatoma growth. Otology and Neurotology Oct; 32(8): pp. 1239-42.
12. Martins O., Victor J., Selesnick S. (2012). The relationship between individual ossicular status and
conductive hearing loss in cholesteatoma. Otology and Neurotology 33(3), pp. 387-92.
13. Jeng, F.C., Tsai, M.H., Brown, C.J. (2003). Relationship of preoperative findings and ossicular
discontinuity in chronic otitis media. Otology and Neurotology 24(1), pp. 29-32.
14. Carrillo, R.J., Yang, N.W., Abes, G.T. (2007). Probabilities of ossicular discontinuity in chronic
suppurative otitis media using pure-tone audiometry. Otology and Neurotology 28(8), p. 1034-7.
15. Bayat, A., Saki, N., Nikakhlagh, S., Farshad M.A., et al., (2019). Ossicular chain defects in adults with
chronic otitis media. The International Tinnitus Journal 23(1), pp. 6-9.
16. Kotzias, S.A., Seerig, M.M., Mello, M.F.P.C., et al., (2020). Ossicular chain reconstruction in chronic
otitis media: hearing results and analysis of prognostic factors. Brazilian Journal of
Otorhinolaryngology 86(1), pp. 49-55.
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Important Anatomical Landmarks of the Orbit for the ENT

Surgeon
SIMION-ANTONIE Catrinel-Beatrice1,2,
BERTEȘTEANU Șerban Vifor Gabriel1,2, POPESCU Bogdan1,2, NIȚU Liliana1,2,
OANCEA Alina1,2, MUNTEANU Gloria Simona1,2,3, BEJENARU Paula Luiza1,2,
CONDEESCU-COJOCĂRIȚĂ Mihnea1,2, NICOLAESCU Alexandru1,4,
CÎRSTEA Anca Ionela2, SIREȚEANU Luiza Maria2, DIMCEA Alisa2,
NEDELCU Ruxandra Ioana2, OAȘĂ Irina2, RUJAN Simona Andreea2,
TAHER Bianca Petra2, DIACONU Teodora Elena2, OTHMAN Amer2,
VETRICEAN Iulia2, MIHALCEA Cătălin Constantin2,
TUDOSIE Mihai Dumitru2, MAGDAN Mădălin2, PAVAL Cristian Costel2,
ENEA Alexandru Gabriel2, PĂUN Oana5, GRIGORE Raluca1,2
1 Universitatea de Medicină și Farmacie “Carol Davila”, Bucharest (ROMANIA)
2 Spitalul Clinic Colțea, Bucharest (ROMANIA)
3 Spitalul Universitar de Urgență Militar Central “Carol Davila”, Bucharest (ROMANIA)
4 Spitalul MAI Prof. Dr. Dimitrie Gerota, Bucharest (ROMANIA)
5 Clinica O.R.L. – Spitalul Județean de Urgență Râmnicu Vâlcea (ROMANIA)
Emails: catrinel.simion-antonie@drd.umfcd.ro, raluca.grigore@3f.ro
Abstract
The ongoing development of endoscopic sinus surgery, along with the proximity of the
orbital structures to the paranasal sinuses and the opportunity to view the anatomical
landmarks from a different angle have opened new ways of approaching pathologies that
affect the orbit and its structures.
The orbit is a bony compartment that hosts the eyeball, neurovascular structures and soft
tissue, surrounded by a thin bony wall, separating it from the paranasal sinuses.
Unfortunately, accidents and incidents related to breaking the bony membrane that
separates the orbit and the paranasal sinuses are frequent during endoscopic sinus surgery, this
is why it is mandatory for every ENT surgeon to study the anatomy, physiology and
pathology of the orbit.
This paper aims to enhance the important anatomical landmarks of the orbit, from an
anatomical, surgical and radiological point of view, related to the surgery of the paranasal
sinuses, the pterygopalatine fossa and infratemporal fossa.
The inferior, posterior and medial wall of the orbit separates the content of the orbit from
the paranasal sinuses, the pterygopalatine fossa and the infratemporal fossa. In order to avoid
incidents and accidents that may occur during surgery, intensive training and study of the
anatomy of this region is necessary, as the orbit hosts a lot of neurovascular elements and the
bony wall is very thin.
The pathology involving this region is frequent, affecting the paranasal sinuses, as well as
the orbit and its content. The approach often requires a multidisciplinary team, in order to
obtain the best outcome. There are also cases in which the orbit and its content are not
affected by the disease, but lesions can occur during surgery and they must be well known
and managed as quickly and effectively as possible.
The ability to manage pathologies or complications that involve both the orbit, and its
structures is based on the knowledge regarding the anatomy of the region and is of great
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interest for every ENT surgeon that approaches the paranasal sinuses, the pterygopalatine
fossa or the infratemporal fossa.
Keywords: orbit, paranasal sinuses, anatomy
Introduction
The ongoing development of endoscopic sinus surgery has completely changed the way
surgeons approach the pathology of the paranasal sinuses in the last decades. The proximity
of the orbit and its structures and the opportunity of seeing the anatomical elements from a
different point of view have opened new ways of managing diseases of the paranasal sinuses
that involve the orbit. [1]
Unfortunately, accidents and incidents that may occur during endoscopic sinus surgery,
related to penetrating the thin bony membrane that separates the paranasal sinuses and the
orbit are frequent, therefore it is mandatory for every rhinologist to know the anatomy,
physiology and pathology of the orbit and to be trained in managing any complications.
Ophthalmic complications can vary from trivial cases to very severe cases, such as optic
nerve damage and blindness. [2]
This paper aims to enhance the important anatomical landmarks of the orbit, from an
anatomical, surgical and radiological point of view, related to the surgery of the paranasal
sinuses, the pterygopalatine fossa and infratemporal fossa. The concept of functional
endoscopic sinus surgery is based on removal of the tissue that obstructs the osteo-meatal
complex in order to facilitate the drainage from the maxillary sinus, while preserving the
normal mucosa. [2]
The technological developments have had a great impact in the surgical technique and
power cutting instruments are currently being used on a daily basis. The field of endoscopic
sinus surgery has extended his indications in ophthalmology, being used in orbital
decompression of thyroid orbitopathy, lacrimal obstruction, optic nerve decompression,
traumatic loss of vision and pituitary tumour surgery. [2]
In order to obtain the best results in pathologies that affect multiple structures, as the
paranasal sinuses or pterygopalatine fossa and the orbit or its content, a multidisciplinary team
is necessary.
Anatomy
The orbit is a bony compartment that hosts the eye, neurovascular structures and soft
tissue.
The configuration of the bony orbit is similar to a four-sided pyramid. Its base is at the
opening of the eye and its apex opens posteriorly and medially. The orbital apex and lateral
orbit are related to the middle cranial fossa. Superiorly, the orbit is related to anterior cranial
fossa. The inferior orbital fissure communicates with the middle cranial fossa. [3], [4]
The orbit has four walls: the roof of the orbit, the medial wall, the lateral wall and the floor
of the orbit. The wall that separates the maxillary sinus and the orbital contents is very thin,
and infectious or other pathological processes can easily penetrate it. [4], [5]
One of the most important landmarks for the ENT surgeon is the orbital septum. It is a
membranous sheet that is attached to the orbital rim and it blends with the periosteum. It
extends in each eyelid and blends with the tarsal plates. The orbital septum runs posteriorly
from the medial palpebral ligament and nasolacrimal duct, but anteriorly from the superior
oblique muscle. It is a very important clinical element, used in the Chandler classification of
orbital complications in rhinosinusitis. [3], [4], [6]
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Regarding the fascial sheet, its envelopes the eyeball from the optic nerve to the
corneoscleral junction. [4]
The ethmoid bone articulates with the orbital blade from the frontal bone by a suture
interrupted by the anterior and posterior ethmoidal foramina. Posteriorly, it articulates with
the body of the sphenoid bone, forming the medial wall of the orbit until the orbital apex. The
lacrimal bone lies anteriorly to the ethmoid and here the nasolacrimal duct can be found. [10]
The floor of the orbit is mainly formed by the bony lamella of the maxillary bone, that
articulates anteriorly and laterally with the zygomatic bone and posteriorly and medially with
the orbital process of the palatine bone. This bony lamella is actually the roof of the maxillary
sinus and it can be affected in trauma. Fractures that involve the floor of the orbit usually
affect the inferior rectus muscle and the patients complains of diplopia. [4], [10]
The roof of the orbit is formed by a bony lamella that separates the orbit from the frontal
sinus and the anterior fossa. Anteriorly and laterally, here lies the lacrimal gland. [10]
The lateral wall of the orbit is formed by the greater wing of the sphenoid bone and frontal
process of the zygomatic bone. This is the thickest wall and separates the orbit from the
middle fossa and the infratemporal fossa. [4]
Surgical Aspects
The medial wall of the orbit is formed, mainly, by Lamina Papyraceea. This is a surgical
landmark that is exposed routinely. This bony lamella, extremely thin, covers the ethmoidal
cells and represents an important element in infection spreading. [6]
The ethmoid bulla usually attaches to the Lamina Papyraceea, but other anatomical
variants must be evaluated prior surgery on the CT scans. [9]
Laterally, the optic nerve may lie in close contact to the posterior ethmoid cells (Onodi
cells) and sphenoid sinus. [9]
During surgery for pathology of the sphenoid sinus, entry should be as far medially and
inferiorly as possible, in order to avoid the injury of the optic nerve and internal carotid artery.
[2]
The tarsal plates are connected to the margin of the orbit by the orbital septum and by the
medial and lateral canthal ligaments. This is very important to know, as lateral canthotomy is
a procedure that needs to be well known and practiced by the ENT surgeon, as it is necessary
in case of lesion of anterior ethmoidal artery with secondary retrobulbar haemorrhage. [4], [7]
In approaching the frontal sinus, the frontal process of the maxilla is an important
landmark that has to be identified during surgery. [4], [8]
The eyeball occupies 1/5 of the orbital volume, the rest being occupied by the 6 extraocular
muscles, nervous structures, blood vessels, orbital fat and connective tissue. The extraocular
muscles are very important for any ENT surgeon and lesion to any of these muscles give
specific defects that have to be identified and managed urgently. During surgery, the medial
rectus and inferior rectus are most frequently damaged, the patient suffering from diplopia
immediately after surgery. [4], [5]
Radiological Aspects
The paranasal sinuses and orbit are structures of high contrasting densities with air, fat and
soft tissue, and computer tomography scan is an accurate way of assessing pathologies in this
area. Both coronal and axial cuts are necessary in order to assess the anatomical landmarks
and make a good surgical plan. [8]
Careful review of the thin-slice CT scans before surgery facilitates the approach and lower
the risk of complications.
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Dehiscence of the Lamina Papyraceea or other developmental anomalies of the medial

orbital wall should be evaluated prior to surgery. The presence of the Onodi cells and the
relationship between the optic nerve and the sphenoid sinus should be noted if the sphenoid
sinus is to be addressed.
The ethmoidal arteries are branches of the ophthalmic artery, that arise from the internal
carotid artery. They have a specific aspect on CT scans and must be evaluated, especially
before frontal endoscopic surgery.
Discussions
The intimate contact between the paranasal sinuses and the orbit makes this area prone to
incidents and accidents.
Because of the thin bony wall that separates these structures, pathological processes can
pass the border and affect both the paranasal sinuses and the orbit.
The ENT surgeon faces the challenge of approaching the orbit in many conditions, such as
complicated rhinosinusitis, malignant or benign tumours, orbital decompression for thyroid
orbitopathy, complicated epistaxis, dacryocystorhinostomy and trauma.
Conclusions
An extensive study of the orbital and periorbital anatomy is necessary in order to

understand the pathology in this region and to apply medical and surgical treatment
effectively and safely.
The ways of prevention, early recognition and early management of orbital complications
in all endoscopic sinus surgery techniques must be well known by all ENT surgeons.
The pathology involving this region is frequent, affecting the paranasal sinuses, as well as
the orbit and its content. The approach often requires a multidisciplinary team, in order to
obtain the best outcome. There are also cases in which the orbit and its content are not
affected by the disease, but lesions can occur during surgery and they must be well known
and managed as quickly and effectively as possible.
REFERENCES
1. Benjamin S. Bleier, Suzanne K. Freitag and Raymond Sacks. 1320. (2018). Endoscopic Surgery of the
Orbit. http://ebookstore.thieme.com/pdfreader/endoscopic-surgery-orbit
2. Abdullah Al-Mujaini, Upender Wali, Mazin Alkhabori. Oman Med J, 2009 Apr; 24(2): pp. 70-80:
Functional Endoscopic Sinus Surgery – Indications and Complication in the Ophtalmic Field
3. Hans-Jürgen Welkoborsky, Burkhard Wiechens and Michael L. Hinni. 1175. (2017). Interdisciplinary
Management of Orbital Diseases http://ebookstore.thieme.com/pdfreader/interdisciplinary-
management-orbital-diseases
4. Susan Standring, Neel Anand, Rolfe Birch, et al.; Grey’s Anatomy The Anatomical Basis of Clinical
Practice , pp. 666-708, 2016, ISBN 978-0-7020-5230-9.
5. Bleotu, Coralia; Chifiriuc, Mariana Carmen; Pircalabioru, Gratiela; et al., VIRULENCE Volume:
5Issue: 8 Pages: 828-831 Published: NOV-DEC 2014 Significance of serum antibodies against HSP 60
and HSP 70 for the diagnostic of infectious diseases.
6. M. Anniko, M. Bernal-Sprekelsen, V. Bonkowsky, P. Bradley, S. Iurato. 2010. European Manual of
Medicine Otorhinolaryngology, Head and Neck Surgery.
7. Stoica, Petruta; Chifiriuc, Mariana Carmen; Rapa, Maria; et al., ROMANIAN BIOTECHNOLOGICAL
LETTERS Volume: 20 Issue: 3 Pages: 10521-10535 Published: MAY-JUN 2015 Fabrication,
characterization and bioevaluation of novel antimicrobial composites based on polycaprolactone,
chitosan and essential oils.
8. Mirea, D.; Grigore, R.; Safta, D.; et al., HIPPOKRATIA Volume: 18 Issue: 2 Pages: 120-124
Published: 2014 Elective Neck Dissection in patients with stage T1-T2N0 carcinoma of the anterior
tongue.
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9. Turvey, Timothy A., and Brent A. Golden. 2012. “Orbital Anatomy for the Surgeon.” Oral and
Maxillofacial Surgery Clinics of North America.
10. Masquelet, Alain C. 2005. “Atlas of Surgical Anatomy.” Atlas of Surgical Anatomy.
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ENT Manifestations in Systemic Diseases
SIREȚEANU Luiza1, BERTEȘTEANU Șerban1,2, NIȚU Liliana1,2,

POPESCU Bogdan1,2, SIMION-ANTONIE Catrinel1,2, BEJENARU Paula1,2,
MUNTEANU Gloria1,2,3, NICOLAESCU Alexandru1,2,4, COSTIN Romeo3,
CONDEESCU-COJOCĂRIȚA Mihnea1,2, CÎRSTEA Anca1, OTHMAN Amer1,
DIACONU Teodora1, NEDELCU Ruxandra1, TAHER Bianca1, RUJAN Simona1,
MITRAN Denisa1, FLORESCU Elena1, OAȘĂ Irina1, DIMCEA Alisa1,
VETRICEAN Iulia1, MIHALCEA Cătălin1, TUDOSIE Mihai1,
MAGDAN Mădălin1, PAVĂL Cristian1, ENEA Alexandru1, GRIGORE Raluca1,2
1 Department of ENT – Colțea Clinical Hospital, Bucharest, (ROMANIA)
2 Carol Davila University of Medicine and Pharmacy, Bucharest, (ROMANIA)
3 Carol Davila Central Military Emergency University Hospital, Bucharest, (ROMANIA)
4 Prof. Dr. Dimitrie Gerota Military Emergency Hospital, Bucharest, (ROMANIA)
Email: luiza-maria.sireteanu@rez.umfcd.ro
Abstract
Systemic diseases can affect the head and neck regions in multiple and different ways. The
ENT manifestations of autoimmune diseases are a diagnostic challenge for clinicians because
they are often the initial indication of the disease. A close collaboration between ENT
specialists, rheumatologists and internists is mandatory to improve the diagnostic and
therapeutic management of these patients. This article is a review of the most common
clinical entities with ENT manifestations.
Keywords: ENT, Systemic diseases, Autoimmune diseases
Introduction
Rheumatic diseases have a high prevalence rate worldwide and the incidence appears to be
increasing, driven by population ageing and exposure to a larger number of inducers of
autoimmune changes. These conditions produce systemic changes involving the connective
tissue throughout the body and involve almost all organs at various stages of the disease. [5]
Otorhinolaryngological symptoms may represent an early sign of an undiagnosed systemic
disorder that often requires immediate and aggressive immunosuppressive treatment. The
most common ENT manifestations of these disorders include bilateral parotid enlargement,
excessive dryness of oral cavity, inflammation of cartilage of pinna & nose, recurrent
sinusitis, sensorineural hearing loss, recurrent oral ulcers, spontaneous septal and palatal
perforations. [1], [4]
Hereditary Haemorrhagic Telangiectasia (Osler-Weber-Rendu Disease; HHT)

It’s an autosomal dominant disorder that affects blood vessels throughout the body
(causing vascular dysplasia) and results in a tendency for bleeding. The vessels have a thin
wall, without smooth muscles and that may cause epistaxis by rupture of the telangiectasis
even after minor trauma, such as nose blowing. The vascular proliferation is high because of
the increased angiogenesis. HHT is manifested by mucocutaneous telangiectases and
arteriovenous malformations. The ENT signs are represented by the characteristic lesions
(telangiectasias) that affect the nasopharynx and are responsible by recurrent and severe
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epistaxis. [1], [6] The main treatment options for hereditary haemorrhagic telangiectasia can
be divided in two major classes: medical management and surgical management. Medical
management: topical moisturizers, topical or oral oestrogen agents, topical timolol, oral
tranexamic acid, topical or intravenous bevacizumab (Avastin). Surgical management:
cauterization using laser, bipolar or radiofrequency, septodermoplasty, Young’s procedure.
[1]
Kawasake Disease (KD)

It is also known as mucocutaneous lymph node syndrome. KD is an acute febrile illness of
early childhood characterized by vasculitis of the medium-sized arteries. The head and neck
symptoms consist in acute unilateral non purulent cervical lymphadenopathy with size >1.5
cm, erythema of tongue (strawberry tongue, protuberance of papillae), erythema of lips and
oral cavity. The treatment consists in early intravenous immunoglobulin and aspirin to
prevent coronary artery disease. [1]
Giant Cell Arteritis (GCA, Temporal Arteritis)

It is the most common vasculitis in adults and it usually affects the older persons. Common
signs and symptoms include headache, jaw claudication, cervical pain and scalp tenderness.
The criterion standard for diagnosis of this granulomatous vasculitis is temporal artery
biopsy. The mainstay of therapy is represented by corticosteroids. [1]
Cogan’s Syndrome
Cogan’s syndrome is a chronic inflammatory condition without a very clear origin.
Clinically, this syndrome comprises three main characteristics: audiovestibular symptoms
similar to the clinical manifestations of Meniere’s syndrome, sudden presentation of tinnitus
and vertigo accompanied by sensorineural hearing loss and ocular symptoms, mainly
interstitial non-syphilitic keratitis. [7] The hearing loss is initial unilateral and high-frequency,
followed by bilateral and progressive and generally definitive installation. If untreated, may
lead to profound sensorineural hearing loss and loss of vestibular function. [1] Examination
may show spontaneous nystagmus and some degree of ataxia. This ataxia to walking is more
marked than vertigo, a ratio most often reversed in Meniere’s disease. Audiovestibular
manifestations result from damage to the inner ear which is often irreversible because it is
associated with degeneration of the sensory of Corty. The MRI of the inner ear may show,
especially in the acute phase, an appearance of labyrinthitis. Treatment of Cogan’s syndrome
involves systemic corticosteroids associated with immunosuppressants. The audiovestibular
syndrome regresses in few days to few months and leads to severe deafness, despite
treatment. Cochlear implants remain the only solution. [2]
Granulomatosis with Polyangiitis (Wegener Granulomatosis)

It is a rare multisystemic autoimmune disease and its main features include necrotizing
granulomatous inflammation and pauci-immune vasculitis in small and medium blood
vessels. The upper respiratory system is the most affected by the disease. The ENT
manifestations include chronic sinusitis, rhinitis, epistaxis, saddle-nose deformity, serous
otitis media, hearing loss and strawberry gingival hyperplasia. Stridor may be also a sign from
tracheal or subglottic granulomatous masses. Also, the main salivary glands can be involved
with pseudotumoral aspect of the parotid or submaxillary glands. The treatment is based on
the combination of systemic corticosteroids and certain immunosuppressants and more recent
on targeted biotherapy. [1], [2]
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Sarcoidosis
Sarcoidosis is a systemic granulomatous condition, of unknown cause, affecting young
adults more frequently, characterized by tissue infiltration consisting of giant cell tuberculoid
granulomas, without associated caseous necrosis. ENT manifestations include sinonasal
sarcoid and nasal symptoms like obstruction, crusting, anosmia or bleeding. The nasal mucosa
has a characteristic granular appearance known as strawberry skin. The anterior nasal septum
is most often affected and may perforate. The nasopharynx may also be involved which
causes otitis media. Patients may accuse a soft-tissue mass or expantion of the nasal bridge.
This may be associated with thickening and purplish discoloration of the overlying skin
known as lupus perino. Another ENT manifestation is the salivary gland enlargement.
Furthermore, Heerfordt’s syndrome may be present and it consists of enlarged parotid
glands, facial nerve palsy, uveitis and fever. The larynx may be also involved, most
commonly the supraglottis, and the dominant symptoms are cough, hoarseness, dysphagia and
stridor. The criterion standard for diagnosis of sarcoidosis is biopsy which shows the classic
histological appearance of noncaseating granuloma with central epithelioid cells surrounded
by lymphocytes and fibroblasts. Oral corticosteroids, immunosuppressive agents, topical
steroids are the principle ways of treatment. Also, in controlled inflammatory disease,
functional endoscopic sinus surgery (FESS) is efficient. [1], [2], [3]
Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome)

It is defined as a necrotizing vasculitis with eosinophil-richi granulomatous inflammation
that affects the upper respiratory tract and is associated with asthma, allergic rhinitis and nasal
polyposis. The ENT most comon manifestations are nasal itching, airflow obstruction, coryza
and recurrent sinusitis. There are three clinical phases of disease: prodromal phase, peripheral
eosinophilic infiltrative phase and disseminated phase with systemic necrotizing vasculitis.
The first phase is characterized by asthma, sometimes associated with allergic rhinitis and
often complicated by nasal polyposis and recurrent rhinosinusitis. The other phases are
manifestations of eosinophilic infiltrates in the tissues or of systemic vasculitis. [5], [1], [2]
Amyloidosis
Amyloidosis is an idiopathic clinical disorder caused by extracellular and/or intracellular
deposition of abnormal amyloid fibrils that alter the normal function of the tissues. Tongue is
the most commonly involved when we refer to ENT manifestations. Furthermore, the larynx
is the most common site of localized deposition in respiratory tract, followed by trachea,
which can lead to subglottic stenosis. [1]
Relapsing Polychondritis
Is an inflammatory condition that involves cartilaginous structures, predominantly those of
the ears, nose and laryngotracheobronchial tree. One of the head and neck manifestations is
represented by the auricular chondritis where patients develop suddenly unilateral or bilateral
auricular pain, swelling and redness. Concomitant with auricular chondritis may appear
audio-vestibular manifestations, such as sudden hearing loss which is usually permanent,
tinnitus and vertigo. Hearing loss is attributed to vasculitic damage of the eighth cranial nerve.
The changes more often found during the physical examination are pinna oedema and
opacity of the tympanic membrane. Another ENT manifestation is nasal chondritis which is
acute and painful and a saddle-nose may develop in longstanding disease. Also, mild epistaxis
may be present. The main nasosinusal symptoms consists of nasal obstruction, rhinorrhoea,
coryza, mucosal oedema, pale mucosa and turbinate hypertrophy. Wheezing, dyspnoea, cough
and hoarseness are the symptoms that appear in respiratory tract chondritis because of
weakening the tracheal cartilage rings. Inflammation and swelling of the laryngeal tissues
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may require tracheostomy. The changes found on physical examination include

interarytenoidal oedema, paresis of vocal folds and laryngeal hyperaemia. [1], [5], [3]
Systemic Lupus Erythematosis (SLE)

Systemic lupus erythematosis is an autoimmune disorder, more frequent in women,
characterized by antibodies to nuclear and cytoplasmic antigens, multisystem inflammation
and relapsing and remitting course. Head and neck manifestations include malar rash, painful
oral mucosal ulcers, cranial neuropathy, acute parotid enlargement, xerostomia and septal
ulceration or perforation. Furthermore, vocal cord thickening or paralysis, cricoarytenoid
arthritis, interarytenoidal oedema and subglottic stenosis are also ENT signs of SLE which
can lead to dysphonia and glottic cleft during phonation. Also, cervical polyadenopathy may
be inaugural and it can be simple reactive (lupus lymphadenitis) or reveal an associated
Kikuchi-Fujimoto syndrome. [1], [2], [5]
Rheumatoid Arthritis (RA)

Rheumatoid arthritis is a chronic systemic inflammatory disease that in predisposed people
is caused by an external trigger (cigarette smoking, infection) that activates an autoimmune
reaction. This is leading to synovial hypertrophy and chronic joint inflammation. Head and
neck manifestations include chronic cricoarytenoid joint involvement with ankylosis leading
to bilateral vocal cord fixation in adducted position. Also, submucosal rheumatoid nodules
may appear in the vocal cords with hoarseness that improves with removal of nodules.
Another ENT manifestation consists of temporomandibular joint arthritis. Also, an
autoimmune inner ear disease may appear which leads to progressive bilateral sensorineural
hearing loss that responds to steroids. [1], [8]
Behcet’s Syndrome
It is a vasculitis disorder characterized by a triple-symptom complex of recurrent oral
aphtous ulcers, genital ulcers and uveitis. For oral ulcerations, topical steroids or sucralfate
solution is the first-line treatment. [1], [3]
Sjogren’s Syndrome
It is an autoimmune connective tissue disorder characterized by xerostomia and
xerophtalmia due to profound lymphocytic infiltration into the exocrine glands, mainly
salivary and lacrimal, causing a drying up of their secretions. The xerostomia of Sjogren’s
syndrome can be profound, giving dysphagia and dysarthria. The oral dryness leads to acute
gingivitis and caries. The most common ENT involvement is the intermittent swelling of the
parotid glands. The installation is often bilateral and symmetrical realizing the Mikulicz
syndrome. It is important to know that there is an increased risk of non-Hodgkin’s lymphoma
of the major salivary gland, mainly MALT tumours. [1], [2]
Pemphigus Vulgaris
This is an autoimmune, intraepithelial, blistering disease that affects the mucous
membranes and the skin. The autoantibodies are directed against keratinocyte cell surfaces.
Mucous membranes of the oral cavity are involved and the gingival, buccal or palatine
erosions are painful and slow to heal. Those erosions may spread to the larynx which leads to
hoarseness. [1], [3]
Sclerodermia
Sclerodermia is an autoimmune connective tissue disease characterized by progressive skin
induration and hardening. Head and neck manifestations consist of difficulty opening the
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mouth secondary to fibrosis of masticatory muscles. The lower oesophageal sphincter

contraction is absent which allows reflux. [1]
Conclusion
Autoimmune (systemic) diseases are a group of various disorders whose ENT

manifestations are common. An otolaryngologist should be aware of the underlying disease as
the ENT manifestations may represent an early sign of an undiagnosed systemic disorder.
Patients with autoimmune diseases must be followed by a multidisciplinary team
(rheumatologist, internist, ENT, ophthalmologist) with early diagnosis and prompt treatment,
which can prevent morbidity and mortality related to these diseases.
REFERENCES
1. A.-Q. Abdulsalam, H. Hassan, et al., (2021) Textbook of Clinical Otolaryngology, Springer, pp. 615-
623.
2. H. Chiraz, T. Safa, et al., (2018) Otolaryngological Manifestations of Systemic Diseases, Scholarly
Journal of Otolaryngology, vol. 1, n. 3.
3. Flint PW, Hughey BH, Lund VJ, et al., (2010) Cummings otolaryngology: head and neck surgery. 5th
ed. Elsevier, pp. 657-661.
4. Chanchal Gera, Navneet Kumar, et al., (2015) Otolaryngologic Manifestations of Various Rheumatic
Diseases: Awareness and Practice Among Otolaryngologists. Indian J Otolaryngol Head Neck Surg
(Oct-Dec 2015) 67(4): pp. 366-369.
5. Balica NC, Poenaru M, Doroş CI, Baderca F, Preda MA, Iovan VC, Stanca HT (corresponding author),
Busuioc CJ, Oprişcan IC, Boruga O. The management of the oropharyngeal anterior wall cancer, Rom J
6. Danielescu, C., Stanca, H.T. (corresponding author), Balta, F. The Management of Lamellar Macular
Holes: A Review. Hindawi Journal of Ophthalmology Volume 2020, Article ID 3526316, 10 pages,
https://doi.org/10.1155/2020/3526316.
7. Preda, M.A., Karancsi, O.L., Munteanu, M., Stanca, H.T. Clinical outcomes of micropulse transscleral
cyclophotocoagulation in refractory glaucoma – 18 months follow-up. Lasers in Medical Science
(2020) https://doi.org/10.1007/s10103-019-02934-x.
8. Boruga O., Balasoiu A.T., Giuri S., Munteanu M., Stanca H.T., Iovanescu G., Preda A.M. Caruncular
late-onset junctional nevus: apropos of an anatomo-clinical observation. Rom J of Morphol Embryol.
2018; 59(1): pp. 113-119; ISSN 1220-0522 (print) ISSN 2066-8279 (online)
9. Stanca, S., Ulmeanu, C. E., Stanca, H.T. (corresponding author), Iovanescu, G. Clinical features in toxic
coma in children. Experimental and Therapeutic Medicine 18, no. 6 (2019): pp. 5082-5087
https://doi.org/10.3892/etm.2019.7857.
10. Gusma˜o RJ, Fernandes FL, et al., (2014) Otorhinolaryngological findings in a group of patients with
rheumatic diseases. Rev Bras Reumatol 54(3):172–178
11. Lessnau KD, Rowe VL, et al., (2020) Osler-Weber-Rendu Disease (Hereditary Hemorrhagic
Telangiectasia) Medscape.
12. Gonzalez JLT, Soto-Galindo GA, et al., (2018) Sudden sensorineural hearing loss in atypical Cogan’s
syndrome: A case report. Annals of Medicine and Surgery, vol 30, pp. 50-53.
13. L. Popovici RA, Vaduva D, Pinzaru I, Dehelean CA, Farcas CG, Coricovac D, Danciu C, Popescu I,
Alexa E, Lazureanu V, Stanca HT. A comparative study on the biological activity of essential oil and
total hydro-alcoholic extract of Satureja hortensis Exp Ther Med. 2019 Aug; 18(2): pp. 932-942. doi:
10.3892/etm.2019.7635. Epub 2019 May 31.
14. O. D. Palade, Florentina Severin, Miorita Toader, M.D. Cobzeanu, Toader Corneliu Combined
approach for large tumours of the nose and paranasal sinuses – case report, The Medical-Surgical
Journal 2016, Vol. 1 (20), pp. 380-383.
15. Toader Corneliu; Stroi Marian; Kozma Andrei; Arsene Dorel Eugen, Esthesioneuroblastoma: the
complete picture – case report and review of the literature, Romanian Journal of Morphology and
16. Bleotu C, Chifiriuc MC, Pircalabioru G, et al., (2014) Significance of serum antibodies against HSP 60
and HSP 70 for the diagnostic of infectious diseases. Virulence; 5(8): pp. 828-31.
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Major Reconstruction Following Salvage Laryngectomy – Case

Report
SPINEANU Ioana-Magdalena1, SUCIU Anamaria1, POP Septimiu Sever2,

MUNTEAN Valentin3
1 ENT Clinic, County Emergency Hospital Cluj-Napoca (ROMANIA)
2 “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, ENT Clinic, County Emergency Hospital Cluj-
Napoca (ROMANIA)
3 “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, Surgery Clinic 2, County Emergency Hospital Cluj-
Napoca (ROMANIA)
Emails: ioaioa19@yahoo.com, anamariasuciu04@gmail.com, severpop@me.com, vmuntean@umfcluj.ro
Abstract
The VA study by the Department of Veterans Affairs Laryngeal Cancer Study Group,
published in 1991, represented a landmark trial in the development of organ-preservation
strategies in managing advanced laryngeal cancer. Despite impressive outcomes, there is a
number of patients who present with local recurrences. For these patients, salvage
laryngectomy remains the single hope for survival. [1], [2]
Salvage surgery continues to be a serious challenge even for the most experienced head
and neck surgeons, mainly because of the high risk of postoperative complications and
prolonged hospitalization.
Keywords: salvage laryngectomy, laryngeal cancer, pharyngocutaneous fistula, reconstructive procedures
Case Report
We present the case of a 59 years old male patient who underwent chemoradiotherapy
(CRT) for a hypopharyngeal carcinoma with ipsilateral hemilarynx invasion in 2018. A local
laryngeal recurrence occurred one year later.
In October 2019, he underwent a salvage total laryngectomy and partial
hypopharyngectomy in our department. Postoperative evolution was marked by serious
complications: four bleedings that required surgical hemostasias in the operating theatre. The
patient presented severe anaemia, which is why he received two blood transfusions. On days
9,28, and 32, after the surgery, the wound secretion had been harvested and the
bacteriological examination identified Candida albicans + Pseudomonas aeruginosa,
Klebsiella pneumoniae, and Enterobacter. The patient received antibiotic treatment according
to the antibiogram. On day 10, after the surgery, a primary hypopharyngeal closure
strengthened with Platelet Rich Fibrin (PRF) was performed unsuccessfully.
The development of a large pharyngocutaneous and eso-tracheal fistula (Fig. 1) required
surgical reconstruction because spontaneous conservative closure was not achieved (antibiotic
treatment, compressive bandage, and feeding tube).
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Fig. 1. Large pharyngocutaneous fistula with necrosis of the cervical skin flap
An evaluation performed by the plastic and reconstructive surgery team concluded that
reconstruction with a free jejunal flap was not amenable because the defect extended in the
upper mediastinum making the lower anastomosis quite impossible.
A subsequent evaluation performed by a general surgeon recommended a gastric
transposition as the most suitable solution.
In May 2020, the patient was hospitalized in the Surgery Clinic 2, County Emergency
Hospital Cluj-Napoca, where the reconstruction was performed using a gastric pull-up
procedure (pharyngo-esophageal reconstruction) (Fig. 2) and a pectoralis major flap (skin
defect reconstruction).
Fig. 2. Anastomosis between the ascended stomach and the tongue base
The postoperative evolution was positive, oral feeding being restored after 14 days.
On day 21, after the reconstruction, the patient developed a minimal pectoralis major flap
skin necrosis that required surgery to remove the necrotic tissue.
Two months later, the patient returned to our clinic for the follow-up. The ENT
examination revealed favourable local evolution (T0N0) (Fig. 3). A contrast CT scan was
recommended one month later.
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Fig. 3. Two months follow-up
Discussions
The introduction of organ preservation protocols represented a big step forward in the
management of advanced laryngeal cancer. Unfortunately, despite impressive reported
outcomes, some patients have recurrences. For these patients, salvage surgery remains the
only chance for survival.
One of the most frequent complications after salvage laryngectomy is pharyngocutaneous
fistula.
In a systematic review published by Hasan et al., 49 of 50 included studies reported
pharyngocutaneous fistula as the most common short-term complication with a mean
incidence of 28.9%. [3]
Klozar et al., report a fistula rate of 20,7%, with a higher incidence among patients who
previously received radiotherapy or chemoradiotherapy (34%), compared to the group of
pacients who had as first treatment total laryngectomy (15%), but the difference is not
statistically significant. [4]
Another systematic review published in 2014 compares fistula rates after primary
laryngectomy (17%) with fistula rates after salvage surgery (37,3%). [5]
Previous chemoradiotherapy, tumour size, higher N classification, pharyngeal extension,
type of neck dissection, wound infection, postoperative haemoglobin, and albumin levels are
the most frequent risk factors for pharyngocutaneous fistula formation. [2], [3], [4]
Our patient presented some of the risk factors for pharingocutaneous fistula formation:
preoperative chemoradiotherapy, T4 stage of tumour, N2a lymph nodes invasion, wound
infection, severe anaemia (Hb-6,9g/dL), and hypoalbuminemia (2.1g/dl).
Management of post salvage laryngectomy pharyngoocutaneous fistula is challenging. The
conservative approach is rarely successful. Most of these patients require surgical treatment
and a reconstructive procedure.
To reconstruct a hypopharyngeal or a hypopharyngo-esophageal defect we can use a loco-
regional axial flap (the deltopectoral fasciocutaneous flap, the pectoralis major myocutaneous
flap), a visceral transposition (stomach, colon), a fasciocutaneous free flap (radial, arm,
thigh), or an enteral free flap (jejunum). [6]
Our case’s particularity was the simultaneous presence of a large pharyngocutaneous and
eso-tracheal fistula extended to the level of the upper mediastinum, with necrosis of the
cervical skin flap. A complex reconstructive procedure was required. First of all,
hypopharyngeal and oesophageal reconstruction was performed using a gastric transposition
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(gastric pull-up). The free jejunal ansa was not considered to be a viable alternative, because
the defect extended in the upper mediastinum making the lower anastomosis quite impossible.
To reconstruct the skin defect, we used a pectoralis major flap.
Repeated wound infections with different microbial agents and repeated bleeding episodes
were other features of this case.
Conclusions
Although not very popular, gastric pull-up remains a reliable procedure in reconstructing
complex defects following salvage laryngectomy.
REFERENCES
1. Wolf GT, Fisher SG, Hong WK et al., Induction chemotherapy plus radiation compared with surgery
plus radiation in patients with advanced laryngeal cancer. N Engl J Med. 1991; 324: pp. 1685-1690.
2. Sewnaik A, Keereweer S, Al-Mamgani A et al., High complication risk of salvage surgery after
chemoradiation failures. Acta Otolaryngol. 2012; 132: pp. 96-100.
3. Hasan Z, Dwivedi RC, Gunaratne DA, Virk SA, Palme CE, Riffat F. Systematic review and meta-
analysis of the complications of salvage total laryngectomy. Eur J Surg Oncol. 2017; 43: pp. 42-51.
4. Klozar J, Cada Z, Koslabova E. Complications of total laryngectomy in the era of chemoradiation. Eur
Arch Otorhinolaryngol. 2012; 269: pp. 289-293.
5. Sayles M, Koonce SL, Harrison L, Beasley N, McRae AR, Grant DG. Pharyngo-cutaneous fistula
complicating laryngectomy in the chemo-radiotherapy organ-preservation epoch. Eur Arch
Otorhinolaryngol. 2014; 271: pp. 1765-1769.
6. Chepeha DB. Reconstruction of the pharynx and oesophagus. In: Flint PV, Haughey BH, Lund VJ et
al., editors. Cummings Otolaryngology – Head and Neck Surgery. Philadelphia: Elsevier Saunders;
2015. pp. 1564-1578.
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A Rare Case of Parotid Gland Teratoma

in a 3 Months Old Patient
ȘTEFAN Cătălin1, LOSTUN Alexandra2,3, LOSTUN Gabriel4,

ȘTEFĂNESCU Dragoș Cristian5,6, HAINĂROȘIE Răzvan5,7
1 Childrens Hospital Brașov (ROMANIA)
2 Forensic Medicine Department Brașov (ROMANIA)
3 Faculty of Medicine, Transylvania University Brașov (ROMANIA)
4 Emergency Military Hospital Queen Mary Brașov (ROMANIA)
5 Carol Davila Medicine and Pharmacy University București (ROMANIA)
6 Gen. Dr. Aviator Victor Atanasiu National Institute of Aeronautical and Space Medicine București (ROMANIA)
7 I.F.A.C.F. Prof Dr Dorin Hociotă București (ROMANIA)
* Corresponding author: Alexandra Lostun
Email: statache_alex@yahoo.com
Abstract
Introduction
The authors of this article are proposing for debate the part of the cervical region pathology
represented by the lateral region of the neck masses/tumours. Out of the large variations we
stopped for the benign tumours section.
Material and method

The case we are taking into discussion is of a 3-months old new-born with a large latero-
cervical tumoral mass on the right side. After a throughout preparation mainly based on
imagistics the surgical act in both diagnostic and curative intention was performed under
general anaesthesia.
Results
The immediate results were good – the patient went well both intra operatively and after.
After 3 months from the initial surgical procedure, he came back with a local/regional
relapse.
Conclusions
No matter the time in life a benign mass in the cervical region appears in a patient the main
problem remains the mass effect and invasion of the noble structures of the head and neck and
by this the final results and the life prognosis is highly affected.
Keywords: teratoma, newborn, cervico-facial surgery, salivary gland
Introduction
The lateral masses of the neck are a well delimited pathology of the cervical region.
Wether these conditions are more or less frequent is a discussion of favorising factors and
of the geographic regions taken into discussion.
This kind of pathology can be divided in many categories as found in specialty literature
books and it can include benign and malignant types. A few of them are cysts, lymphnodes,
branchial cysts, malignant tumours of the skin, conjunctive tissue, muscles, vascular tumours
and bone structures tumours. The happy case if we can say that are the inflammations and
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infections of the neck spaces and structures. However, the conditions in this anatomic area
even if benign by histopathology exam can have life threatening aspects as they can have
close contact with vital structures such as the carotid artery, jugular vein and nerves of the
neck.
Out of al the histology types the teratomas are not a usual finding in the parotid gland –
only as metastasis.
A teratoma with malignant transformation is a very rare form of teratoma that may contain
elements of somatic malignant tumours such as leukaemia, carcinoma, or sarcoma. [1] Of 641
children with pure teratoma, nine developed TMT: [2] five carcinomas, two glioma, and two
embryonal carcinomas
Material and method
The authors chose to present in this article the case of a 3 months old infant who was
referred to Children’s Hospital Brasov for a right side of the neck mass that was deforming
the cervical region as seen in Picture 1.
Picture 1. Image of the lateral mass before surgery
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The mass was investigated clinical and by imagistic methods. A pediatric and ENT
surgeon team was gathered. The tumour was described as having multiple extensions to the
nearby structures. Picture 2 and 3 show the imagistic aspects of the tumour.
Picture 2. Extension to the deep neck spaces and temporal lobe
Picture 3. Lateral and posterior extension
In order to clarify the origin of the pathology and as on-site pathology analysis was not
available the decision was to enter the surgery room and try and as radical as possible surgical
act. An informed consent was obtained from the parents. Overall status of the child was good
and no history of such tumours was present in the close relatives. General anaesthesia with
orotracheal intubation and a 5-day hospitalization was needed.
Results
The surgical act meant an about 3 hours intervention during which the tumour was
mobilized as much as possible. Dissection and preservation of most branches of the facial
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nerve was possible – picture 4. However, a part of about 10% of the mass was impossible to
resect as it entered the parapharyngeal space.
Picture 4. Intraoperatory view of the tumour and facial nerve branches
The patient had a good immediate evolution but unfortunately 2 months after surgery a
recidive appeared. The tumour grew even bigger than the first time and it reached the
pharynx, the temporal lobe of the brain through bone tissue extension near the clivus with no
demarcation limit and had 75/48/46 mm dimensions. It also had a zygomatic extension. Two
lymph nodes with pathological appearance were described – 28/25 and 11/8 mm in diameter.
The tumour was moderately absorbing the contrast substance.
The child was then referred to another pediatric facility by the parents and underwent
second surgery without facial nerve preservation.
Our histopathology result was grade 4 undifferentiated teratoma.
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Conclusions
Tumours in general have a difficult management and in our case as it affected a child the
impact was even greater. Teratomas are not a usual finding when performing surgery on the
cervical region and more than that at the level of the parotid gland.
As it was diagnosed already in stage 4 the prognosis was very poor and probably
incompatible with survival in less than a year.
In such cases the age of the patient combined with the aggressivity of the tumour almost
does not leave any space and time for the patient and surgeon at the same time. The
impossibility of having a good resection margin can be frustrating for the surgeon but at the
same time one should remember that the patient life is at stake before anything and especially
surgical esteem.
The case is considered interesting by the authors through the pathology diagnostic which is
uncommon in this localisation.
Discussions
This case once again emphasizes the importance of previous conception, intrauterine and
right after birth genetic and risk tests importance. This may be of even greater importance as
it regards the forensic medicine point of view on the matter. If correct risk is appreciated in
time and correct diagnostic is given as quick as possible then with current methods of surgery
even during intrauterine life a better prognosis in these cases can surely be achieved.
In such cases it is very important to explain fully the risks of the surgical act, obtain a truly
informed consent and be sure to offer options to the patient if these are available.
REFERENCES
1. Harms D, Zahn S, Göbel U, Schneider DT (2006). “Pathology and molecular biology of teratomas in
childhood and adolescence”. Klinische Pädiatrie. 218(6): pp. 296-302. doi:10.1055/s-2006-942271.
PMID 17080330
2. Biskup W, Calaminus G, Schneider DT, Leuschner I, Göbel U (2006). “Teratoma with malignant
transformation: experiences of the cooperative GPOH protocols MAKEI 83/86/89/96”. Klinische
Pädiatrie. 218(6): pp. 303-08. doi:10.1055/s-2006-942272. PMID 17080331
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Features in HPV Positive Oropharyngeal Cancer
TAHER Bianca Petra1, GRIGORE Raluca1,2, NIȚU Liliana1,2,

POPESCU Bogdan1,2, OANCEA Alina Lavinia1,2,
ANCA Moșoiu1, MUNTEANU Gloria Simona1,2,3, COSTIN Romeo3,
CONDEESCU-COJOCĂRIȚA M.1,2, NICOLAESCU A.1,2,4, OTHMAN A.1,
POPA Teodora1, DIMCEA Alisa1, NEDELCU Ruxandra Ioana1,
DIACONU Teodora Elena1, CIRSTEA Anca Ionela1, RUJAN Simona Andreea1,
SIREȚEANU Luiza Maria1, OAȘĂ Irina1, MITRAN Denisa Maria1,
FLORESCU Elena1, ANDRONE Roxana1, VETRICEAN Iulia1,
MIHALCEA C.C.1, TUDOSIE M.D.1, MAGDAN M.1, PAVĂL C.C.1,
ENEA A.G.1, TEODORESCU Arghezi Ertan1, BERTEȘTEANU Ș.V.G.1,2
1 ENT Department, Coltea Clinical Hospital, Bucharest, (ROMANIA)
2 “Carol Davila” University of Medicine and Pharmacy, Bucharest, (ROMANIA)
3 Cental Military Emergency Hospital “Carol Davila”, Bucharest, (ROMANIA)
4 Dr. Professor Dimitrie Gerota Emergency Hospital, Bucharest, (ROMANIA)
Email: biathaer@gmail.com
Abstract
Introduction
Despite the decrease of exposure to smoking and alcohol consumption, the incidence of
oropharyngeal cancer is growing, being linked to HPV infection, especially HPV 16.
Including HPV infection as an etiological risk factor alters some features such as
epidemiology, clinical presentation, TNM staging and reviewing the possibility of a
prevention plan.

A retrospective analysis was performed whereby demographic and clinical data of 20
patients with HPV positive oropharyngeal cancer detected though p16 immunohistochemistry
admitted in the ENT ward of Coltea Clinical Hospital between 2019 and 2020 were obtained
regarding age of patients, gender, history of tobacco and alcohol use, site of primary tumour,
TNM classification, stage at presentation, and modality of treatment including surgery,
radiation therapy and systemic therapy.
Results
HPV positive oropharyngeal squamous cell carcinoma is seen in younger patients with
lower exposure to tobacco and alcohol, with a higher socio-economic status, have a higher
nodal stage and are related to a favourable prognosis.
Conclusions
Classifying HPV infection as a risk factor for oropharyngeal cancer urges us to review
patient education plans, diagnostic and staging steps and treatment methods.
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Introduction
Epidemiology and clinical features

HPV16 is responsible for almost 90% of oropharyngeal squamous cell carcinoma
(OPSCC) cases [1]. Traditionally, tobacco and alcohol related oropharyngeal cancer usually
affects older patients, whereas HPV positive OPSCC is known to be seen in younger adults
with having little to no history of tobacco and alcohol abuse [2]. In our set of 20 subjects, the
mean age at presentation is 57.8 years. In both instances, men are most likely to rate to
develop oropharyngeal cancer. The prevalence of HPV positive OPSCC is also related to the
region of provenance and to socio-economic status. Therefore, adults living in urban areas,
with a higher socio-economic status, combining certain behavioural risks such as multiple
sexual partners or early onset of sexual activity) seem to be contributory factors [3].
Staging and prognosis

Another key feature is tumour characteristics. Compared with HPV-negative OPSCC, the
primary HPV-positive tumour is generally smaller, but is accompanied by greater cervical
nodal disease. This distinct biology pushed the American Joint Committee on Cancer (AJCC)
to develop a new edition of the TNM classification system, making HPV-positive and HPV-
negative OPSCC different entities from this point of view. The new edition of the TNM
classification system (UICC/AJCC) became available January 1st, 2017 (Table 1). For the first
time, HPV-positive and HPV-negative OPSCC are classified as separate entities.
Compared to traditional risk factor related oropharyngeal cancer, HPV positive OPSCC is
associated with a better prognosis and lower death rate. This is mainly due to better
locoregional control of the tumour, since the incidence of distant metastases is similar in both
HPV negative and positive oropharyngeal cancer [4], [6].
Table 1. TNM staging for HPV+ oropharyngeal cancer (AJCC 8 th edition)
A retrospective analysis was performed whereby demographic and clinical data of 20

patients admitted in the ENT ward of Coltea Clinical Hospital between February of 2019 and
January of 2020. Patients of all ages, genders and of different regions of provenance were
chosen according to the following inclusion criteria: primary lesions of the oropharynx and its
subsites, a histological diagnosis of oropharyngeal squamous cell carcinoma, HPV p16
immunohistochemistry diagnosis. Patients with high smoking index were excluded.
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Results
The overall mean age at diagnosis was 57.8, 79 years being the oldest and 49 the youngest.
76% of patients were males and most of which were from urban regions of the country.
The most common primary tumour site was the tonsil, followed by the base of tongue and
very few soft palate cases. Most of the patients presented with stage III disease (55%), none
of which had any distant metastasis. Almost all patients, specifically 80%, underwent dual-
modality treatment that included surgery followed by external radiotherapy and the remaining
20% received radiochemotherapy.
Case Presentation
A 52-year-old male patient who was referred to the ENT Clinic of Coltea Hospital
diagnosed with an HPV positive OPSCC thought p16 immunohistochemistry, with no
remarkable past medical history, known to consume a moderate amount of alcohol and has
smoked almost one pack a day for 15 years (15 pack years) completing the diagnostic workup
and treatment. According to the eighth edition of TNM AJCC staging system, this is a
T4N3M0 stage IV. The patient underwent surgical therapy that included bucopharyngectomy
extended to the lateral wall of the nasopharynx via mandibulotomy and partial
glosoplevectomy (Figure 1). The surgical defect was repaired using a myocutaneous
sternocleidomastoid flap (Figure 2 and Figure 3). The patient underwent external radiotherapy
six weeks postoperative.
Fig. 1. Fig. 2. Fig. 3.
Conclusions
These cancers usually present in younger, healthier individuals who might not have the
typical risk factors for head and neck cancers and could therefore go unnoticed. The majority
are HPV16 subtype positive [8], as in most cervical cancer. HPV positive OPSCC represents
a distinct entity of head and neck squamous cell carcinoma due to the different risk factors,
clinical presentation and afferent new edition TNM AJCC staging and better prognosis, which
currently represents a global epidemic. This calls for an alteration in existing treatment
strategies. Until then, the foundation of treatment is an interdisciplinary team approach with
emphasis on quality of life during the treatment and survivorship periods. It is also important
to highlight that smoking prevention remains the main strategy in preventing and controlling
head and neck cancers.
REFERENCES
1. Epidemiology of HPV-associated oropharyngeal cancer. Oral Oncol Pytynia, K.B.; Dahlstrom, K.R.;
Sturgis, E.M. 2014, 50, pp. 380-386.
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2. The current and future impact of human papillomavirus on treatment of squamous cell carcinoma of the
head and neck Psyrri, A.; Rampias, T.; Vermorken, J.B. Ann. Oncol. 2014, 25, pp. 2101-2115.
3. Distinct biomarker and behavioural profiles of human papillomavirus-related oropharynx cancer
patients by age Fakhry, C.; Waterboer, T.; Westra, W.H.; Rooper, L.M.; Windon, M.; Troy, T.; Koch,
W.; Gourin, C.G.; Bender, N.; Yavvari, S.; et al., Oral Oncol. 2020, 101, 104522.
4. Oral cavity and oropharyngeal squamous cell carcinoma in young adults: a review of the literature.
Majchrzak E, Szybiak B, Wegner A, et al., Radiol Oncol. 2014; 48: pp. 1-10. doi: 10.2478/raon-2013-
0057.
5. Human papillomavirus and survival of patients with oropharyngeal cancer. Ang, K.K.; Harris, J.;
Wheeler, R.; Weber, R.; Rosenthal, D.I.; Nguyen-Tan, P.F.; Westra, W.H.; Chung, C.H.; Jordan, R.C.;
Lu, C.; et al., N. Engl. J. Med. 2010, 363, pp. 24-35.
6. The management of the oropharyngeal anterior wall cancer Balica NC, Poenaru M, Doroş CI, Baderca
https://doi.org/10.3892/etm.2019.7857.
doi: 10.3892/etm.2019.7635. Epub 2019 May 31.
https://doi.org/10.1155/2020/3526316.
https://doi.org/10.1007/s10103-019-02934-x.
2016, Vol. 1 (20), pp. 380-383.
14. Detection of human papillomavirus (HPV) in clinical samples: Evolving methods and strategies for the
accurate determination of HPV status of head and neck carcinomas. Westra, W.H. Oral Oncol. 2014,
50, pp. 771-779.
15. Madrigal E, Bishop JA, Faquin WC. Head and neck cytopathology: human papillomavirus-positive
carcinomas, including diagnostic updates, testing modalities, and recommendations. Surg Pathol Clin.
2018; 11(3): pp. 501-4.
By: Bleotu, Coralia; Chifiriuc, Mariana Carmen; Pircalabioru, Gratiela; et al., VIRULENCE Volume: 5
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Tracheo-bronchial Foreign Bodies in Tracheostomized Patients. A

Review of the Most Frequent Causes and Treatment Methods
TUDOSIE Mihai Dumitru1*, GRIGORE Raluca1,2,

MUNTEANU Gloria Simona2,4, PAUN Oana Alexandra3,
CONDEESCU-COJOCARITA Mihnea Florin1,2, BEJENARU Paula1,2,
SIMION-ANTONIE Catrinel Beatrice1,2, NITU Liliana1,2,
CIRSTEA Anca Ionela1, SIRETEANU Luiza Maria1, DIMCEA Alisa1,
NEDELCU Ruxandra Ioana1, TAHER Bianca Petra1, RUJAN Simona Andreea1,
POPA Teodora1, DIACONU Teodora Elena1, OANCEA Alina1,
NICOLAESCU Alexandru2, OTHMAN Amer1, VETRICEAN Iulia1,
MIHALCEA Catalin Constantin1, MAGDAN Madalin1,
PAVAL Cristian Costel1, ENEA Alexandru Gabriel1, COSTIN Romeo4,
BERTESTEANU ȘerbanVifor Gabriel1,2
1 E.N.T. Head & Neck Surgery Clinic – “Colțeaˮ Clinical Hospital Bucharest, (ROMANIA)
2 E.N.T. Head & Neck Surgery Department – “Dr. Carol Davilaˮ University of Medicine and Pharmacy – General Medicine
Faculty – Bucharest, (ROMANIA)
3 E.N.T. Department, County Emergency Hospital “Valcea”, (ROMANIA)
4 E.N.T. Department, Central Military Hospital, Bucharest, (ROMANIA)
* Corresponding author: TUDOSIE Mihai Dumitru
Email: mmihai.tudosie@scout.ro
Abstract
The present study reviews a series of articles that present different cases of foreign bodies
impacted in the bronchial tree in tracheostomy patients. As a reference we will present a case
of a patient that aspirated a voice prosthesis, a case of a child and an adult with parts of the
tracheostomy tube impacted in the bronchial tree and a patient that mismanaged the
tracheostomy care techniques and aspirated a pair of tweezers.
A tracheostomy itself represents a risk for aspiration of foreign bodies. Which implies that
tracheostomized patients should be well informed about the correct techniques in daily
tracheostomy care.
Foreign bodies in the bronchial tree represent a challenge for both the surgeon and the
anaesthesiologist due to the sharing of the upper airway.
The foreign bodies most often involved in aspiration are fragments of the canula or the
tube itself that detaches from the shield. Therefore, tracheostomy accessories manufacturers
should research new materials and better designs to prevent corrosion of those components.
Furthermore, patients should be advised and helped financially to replace tracheostomy
tubes as often as possible.
Voice prosthesis represent one of the most dangerous objects to be aspirated in the
bronchial tree due to the fact that it consists of a uni-directional valve that can allow the
passage of air to the lungs but not back out or vice-versa depending on its impacted position.
Patients should be warned of the risks of displacing the prosthesis when the canula is
inserted.
Physicians should allow a period of time while the patient is under supervision in the
hospital to teach them on how to safely manage the tracheostomy, tracheostomy tubes and
voice prosthesis.
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Removing tracheobronchial foreign bodies using a rigid bronchoscope and forceps still
remains the gold-standard but there are selected cases where a flexible bronchoscope can be
used. Sometimes, the foreign body may require open surgery in order to be extracted.
Keywords: Tracheostomy, foreign body, tracheostomy tube, canula, aspiration, voice prosthesis, bronchoscopy
Introduction
The bronchial tree represents the system through which oxygen-saturated air reaches from
the larynx to the pulmonary alveoli where gas-exchange process takes place and the
elimination of carbon dioxide-saturated air in the opposite direction.
It is formed of the trachea, a flexible tube that continues the larynx inferiorly to the T4-T5
intervertebral disk where it divides into the two main bronchia, then segmental bronchia and
further into bronchioles and ending in the pulmonary acina. The right main bronchus is larger
in caliber and also situated at an almost vertical level, therefore the foreign bodies tend to
impact into it more often than in the left main bronchus. [1], [2]
Tracheostomy patients are more susceptible to foreign body aspiration due to the larger
and more exposed communication between the airways and the environment. Any aspiration
is considered a life-threating condition therefore fast diagnosis and treatment are of the
outmost importance. [3]
Material and method
The present study reviews a series of articles that present different cases of foreign bodies
impacted in the bronchial tree in tracheostomy patients. The article relies on the study of
international literature published by clinics with valuable experience regarding the care of
tracheostomized patients spanning from 2010 to 2019.
Results
A tracheostomy is the surgical formation of an opening into the trachea through the neck to
allow the passage of air [15]. There are many classifications of the types of tracheotomy and
they refer to the placement of the opening, type of incision, temporary or permanent character,
the approach of the thyroid isthmus etc.
The foreign body aspiration in tracheostomized patients is a rare condition but it represents
a challenge for both the surgeon and the anaesthesiologist. The stoma represents a perfect
gateway for aspiration and the lack of awareness in tracheostomy care can produce a series of
accidents with fatal consequences if immediate treatment is not assured.
Many anaesthesia articles present the cases of tracheal and bronchial foreign bodies as a
challenge due to the fact that the airways are used both by the surgical team and the
anaesthesiologist. Furthermore, positive pressure ventilation can displace the foreign body
converting a partial obstruction into a complete obstruction or push the body further into the
bronchial tree. Sedative medication is not warranted due to the risk of suppressing respiratory
drive. [5], [6]
According to a study conducted in the Clinic of Chest Diseases, Yedikule Chest Diseases
and Chest Surgery Training and Research Hospital, İstanbul on 28 adult patients, 3 patients
were previously tracheostomized and wearing a tracheostomy tube and speech prosthesis and
in all 3 cases the speech prosthesis was aspirated. Removal of the foreign bodies was
performed under rigid bronchoscopy. [4]
A study from the Department of ENT&HNS, Sri Siddharha Medical College&Hospital,
Tumkur, Karnataka presents a case of a 42-year-old, male tracheostomized patient presenting
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for mild respiratory distress. The patient noticed that the tracheostomy tube was broken and
only the shield was in place after the daily routine of changing said tube. Measuring the
patient’s vitals revealed a mild tahypneea (22/minute) with a saturation in oxygen of 97% in
air. The chest X-ray revealed the fractured tracheostomy tube impacted in the main left
bronchus, due to its curvature.
Fig. 1. Chest X-ray showing the aspirated tracheostomy tube impacted in the left main bronchus
(Fractured Tracheostomy Tube-An unusual Foreign Body in Tracheobronchial Tree – Sanu P. Moideen, G.
Arun, M. Mohan, Khizer Hussain Afroze)
The extraction was performed using a bronchoscope forceps under visual control from a 0o
4mm Storz® nasal endoscope. After the procedure a new tracheostomy tube was inserted and
the patient was kept under observation in the ICU for 12 hours and discharged the next day
with instructions regarding tracheostomy care and regular follow-up routine. [8]
A rare case of a fragmented tracheostomy tube is presented by Poduval J. of Department of
Ear, Nose and Throat, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India
when a 5-year-old-boy, with a known case of bilateral recurrential paralysis with the vocal
cords in abducted position and subglottic stenosis, diagnosed at birth and tracheostomized at 1
month of age presented with coughing and dyspnoea with sudden onset. A quick inspection of
the tube revealed that the flange and the tubular portion were separated, only the flange being
visible, attached with tape. A chest X-ray revealed the tubular portion lodged in the trachea.
An attempt to aspirate the foreign body resulted in dislodging the tube and pushing it
further into the trachea, followed by the aggravation of the respiratory distress.
Fig. 2. X-ray of the broken tracheostomy tube impacted in the trachea (Poduval J, Benazir F., Ninan P.
Pneumopericardium – an unusual complication of broken tracheostomy tube presenting as foreign body trachea)
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The extraction was performed with rigid bronchoscopy and the patient was intubated with
a size 4 uncuffed endotracheal tube due to the unavailability of a proper sized tracheostomy
tube. After a few hours the patient developed subcutaneous emphysema, pallor, tachycardia
and sweating. A follow-up chest X-ray shows the development of pneumopericardium at
which point Trendelenburg position and oxygen intake supplementation (2liters/minute) were
applied. After this, the emphysema diminished without further complications. The
endotracheal tube was replaced with a size 18 Fuller’s tube the next day and the patient
recovered and was discharged after 3 days. [9]
A case study from Erciyes University Faculty of Medicine, Kayseri, Turkey presents a 78-
year-old male patient tracheostomized due to laryngeal cancer admitted for aspiration of a pair
of tweezers whilst performing the daily tracheostomy hygiene routine. The patient accused
coughing and dyspnoea. Physical examination revealed central cyanosis and diminished
vesicular murmur in the right lung. Chest X-ray revealed the tweezers impacted in the main
right bronchus, right after the carina.
A. B.
Fig. 3. A – Chest X-ray revealing the tweezers lodged into the main right bronchus; B – Foreign body after
removal (Foreign Body Aspiration from Tracheostomy Inlet- PolatDurukan, Ali Duma, Seda Özkan, Ömer Salt,
Leyla Hasdıraz, FahriOğuzkaya)
Emergency rigid bronchoscopy was performed and the foreign body was observed as a
bright reflection in the main right bronchus. It was extracted using a bronchoscopy forceps. A
control X-ray was performed after the surgery, revealing no remains of the foreign body or
any other subsequent pathology. The patient was discharged after a few days and was advised
about proper technique in tracheostomy care. [10]
Conclusions
A tracheostomy itself represents a risk for aspiration of foreign bodies. That implies that
tracheostomized patients should be well informed about the correct techniques in daily
tracheostomy care.
Foreign bodies in the bronchial tree represent a challenge for both the surgeon and the
anaesthesiologist due to the sharing of the upper airway.
The foreign bodies most often involved in aspiration are fragments of the canula or the
tube itself that detaches from the shield. Therefore, tracheostomy accessories manufacturers
should research new materials and better designs to prevent corrosion of those components.
Furthermore, patients should be advised and helped financially to replace tracheostomy
tubes as often as possible.
Voice prosthesis represent one of the most dangerous objects to be aspirated in the
bronchial tree due to the fact that it consists of a uni-directional valve that can allow the
passage of air to the lungs but not back out or vice-versa depending on its impacted position.
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Patients should be warned of the risks of displacing the prosthesis when the canula is
inserted.
Physicians should allow a period of time while the patient is under supervision in the
hospital to teach them on how to safely manage the tracheostomy, tracheostomy tubes and
voice prosthesis.
Removing tracheobronchial foreign bodies using a rigid bronchoscope and forceps still
remains the gold-standard but there are selected cases where a flexible bronchoscope can be
used. Sometimes, the foreign body may require open surgery in order to be extracted.
REFERENCES
1. Drake R.L., Vogl W., Mitchell A.W.M. – Gray’s Anatomy for Students, Second Edition.
2. Ranga V. – Viscerele Toracelui.
3. Altuntas A., Aydin Y., Eroglu A., – Foreign body in Trachea: A 25-year Experience 2016.
4. Ozdemir C., SN. Sökükü., Karasulu L., Büykkale S., Dalar L. – Foreign Body Aspiration in Adult:
Analysis of 28 Cases. 2015.
5. Kendigelen P. – The Anaesthetic Consideration of Tracheobronchial Foreign Body Aspiration in
Children 2016.
6. Bould M.D. – Essential Notes: The Anaesthetic Management of an Inhaled Foreign Body in a Child.
2019.
7. Fidkowski C.W., Zhang H., Firth P.G. – The anaesthetic Considerations of Tracheobronchial Foreign
Bodies in Children. A Literature Review of 12,979 Cases 2010
8. Moideen S.P., Arun G., Mohan M., Afroze K. H. – Fractured Tracheostomy Tube-An unusual Foreign
Body in Tracheobronchial Tree 2017.
9. Poduval J, Benazir F., Ninan P. – Pneumopericardium – An Unusual Complication of Broken
Tracheostomy Tube Presenting as Foreign Body Trachea 2014.
10. Durukan P.t, Duma A., Özkan S., Salt Ö., Hasdiraz L., Oğuzkaya F. – Foreign Body Aspiration from
Tracheostomy Inlet 2014.
11. Laza C., Sarv M. – Is Tracheostomy A Risk for Foreign Bodies Aspiration? – Case Report 2017.
https://doi.org/10.1155/2020/3526316.
https://doi.org/10.1007/s10103-019-02934-x.
https://doi.org/10.3892/etm.2019.7857.
doi: 10.3892/etm.2019.7635. Epub 2019 May 31.
2016, Vol. 1 (20), pp. 380-383.
20. Stoica, Petruta, Chifiriuc, Carmen M., Rapa M. et al., – Fabrication, characterization and bio-evaluation
of novel antimicrobial composites based on polycaprolactone, chitosan and essential oils ROMANIAN
BIOTECHNOLOGICAL LETTERS Volume: 20 Issue: 3 Pages: 2015 10521-10535.
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21. Mirea D., Grigore R., Safta D., et al., – Elective Neck Dissection in patients with stage T1-T2N0
carcinoma of the anterior tongue HIPPOKRATIA Volume: 18 Issue: 2 Pages: 2014 120-124.
22. Bleotu, Coralia; Chifiriuc, Mariana Carmen; Pircalabioru, Gratiela; et al., – Significance of serum
antibodies against HSP 60 and HSP 70 for the diagnostic of infectious diseases. VIRULENCE Volume:
5 Issue: 8 Pages: 2014 828-831
23. Merriam-Webster Dictionary.
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Submandibular Abscess of Dental Origin and Its Evolution, in

Immunosuppressed and Non-Collaborated Patients. Clinical Case
VENTER Ciprian1, MĂRGINEAN Emil1, POPA Amorin3, MANOLE Felicia1,

CIAVOI Gabriela2, DOMUȚA Maria1
Oradea, 1st December Square 10, 410068 Oradea, (ROMANIA)
2 Department of Dental Medicine, Faculty of Medicine and Pharmacy, University of Oradea, 1 st December Square 10,
410068 Oradea, (ROMANIA)

3 Medical Department Faculty of Medicine and Pharmacy, University of Oradea, 1 st December Square 10, 410068 Oradea,
(ROMANIA)
Emails: cypry_85@yahoo.com, clinicaorloradea@yahoo.ro, manole.felicia@gmail.com, maria.domuta@yahoo.com,
gabrielaciavoi@gmail.com, popa_amorin@yahoo.com
Abstract
We present a case of a 36-year-old female patient with type 2 (non-insulin-dependent)

diabetes mellitus, who was admitted urgently to the ER service accusing the following signs
and symptoms: asymmetry of the face with Celsius signs presence at the submandibular on
the right side, trismus, febrile syndrome. The clinically conscious patient refuses
hospitalization, therefore it was the reason for leaving the ER with oral treatment, and a
recommendation to perform a dental consultation as soon as possible. Surgical intervention is
performed, with multiple incisions, both external and endooral incisions, with the collection
of secretion for culture (no germs have grown). Medical treatment drugs parenteral
antibiotics, oral antidiabetics, and insulin was administered continued.
The purpose of the paper was to highlight patient compliance and cooperation.
In our case, delaying the discharge of an abscess, by about 48 hours with an uncooperative
patient with diabetes, led to multiple complications and prolonged hospitalization.
Keywords: Submandibular abscess, Diabetes mellitus, Immunosuppression
Introductions
The cervico-facial region is frequently affected by suppurative processes. The anatomo-

clinical forms are acute, chronic cellulite (or chronic inflammation cellulite?), abscess, and
phlegmon. Cellulite is the expression of inflammation; it is characterized by vasodilation.
Clinical examination shows a swelling sensitive (sensitivity?) to palpation, but without
areas of fluctuation. [1, 5].
The abscess is the expression of a limited suppuration, the clinical examination marking
the appearance of fluctuation. The overlying skin is relaxed, erythematous, and the general
condition becomes altered, with fever, tachycardia. Phlegmon has the clinical characteristics
of an abscess, but it is an extensive suppuration, with no clear limits in relation to the
neighbouring (surrounding) tissues. Clinically, a massive, hard, fluctuating or crackling
swelling is detected. [1, 5]
Infections of the cervico-facial area are at the border of the areas of competence of ENT
and oromaxillofacial surgery, the correct, complete and coherent management most frequently
requiring the contribution of specialists from both branches of surgery. [1, 2, 3, 5]
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Classification of cervico-facial suppurations will be done mainly in relation to the affected

anatomical area. A classification as complete as possible contains [1, 2, 3, 5, 6]:
1. Bone infections – osteoperiostitis, osteitis, osteomyelitis (acute suppuration, conical
suppuration, and un suppuration), osteonecrosis,
2. Dangerous space – mandibular body, palatal space, vestibular space,
3. Lymphadenitis,
4. Necrotizing (fasciitis),
5. Infections and suppurations of the fascial spaces.
1. Maxillary space
2. Mandibular space (sublingual, submandibular, submental)
3. Masticatory space (masseter, pterygomandibular, temporal)
4. Pharyngeal space (periamygdalian, retropharyngeal, lateropharyngeal,
prevertebral phlegmon, phlegmonous lingual periamygdalitis, epiglottis abscess)
5. Localized abscesses (tongue, orbit)
6. Diffuse suppurations (phlegmon of the buccal floor, diffuse hemifacial phlegmon,
diffuse phlegmon of the pharynx – Senator’s disease)
7. Specific infections (actinomycosis, syphilis, TB)
8. Abscessed malignant/benign tumours
Etiopathogenesis
Etiopathogenesis involves multiple starting points for cervicofacial suppurations in general

and latero-cervical (parapharyngeal) in particular. The most common are dental foci; both
dento-periodontal pathology and complications of anaesthesia and dental interventions. [1, 4,
5, 6]
Other cited causes are foreign bodies including pharyngeal, trauma, salivary gland stones,
benign or malignant tumours superinfected and abscessed, but also pharyngeal-tonsillar
infections, neglected, incorrectly treated or under immunosuppression. [1, 3, 4, 5]
The pathogenic flora involved is a polymorphic one, the infections being in the proportion
of over 85% plurimicrobial infection, most frequently the beta-hemolytic Streptococcus,
Staphylococcus aureus and Pseudomonas aeruginosa. The germs involved are predominantly
aerobic. [1, 5, 6]
Clinical case
Material and method

We present the case of a 36-year-old female patient known to have type 2 (non-insulin-
dependent) diabetes mellitus, who presents urgently in the ER accusing the following signs
and symptoms: asymmetry of the face with the presence of local submandibular Celsius signs
on the right side, trismus, febrile syndrome. Clinically conscious patient, refuses
hospitalization, therefore of the reason for leaving the ER with oral treatment and the
recommendation to perform a dental consultation as soon as possible.
Returns to the ER in about 48 hours with marked edema of the right hemifete and right
later cervical, moderate respiratory failure, Celsius signs mark present on the right latero-
cervical.
Emergency CT examination that reveals the presence of a right latero-cervical collection
with diffusion to the amygdala lodge and the lateral wall of the pharynx on the right side, as
well as marked cellulite in the right hemifete.
Surgical intervention (Fig. 1preoperator, Fig. 2 post-operator) is performed, with multiple
incisions, both external and endooral incisions, with the collection of secretion for culture (no
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germs have grown). Medical treatment drugs parenteral antibiotics, oral antidiabetics, and
insulin was administered continued.
Fig. 1. Fig. 2.
Interdisciplinary diabetology consultation is requested in order to regulate glycaemic

values (insulin and oral antidiabetics) because the patient does not follow the 200 HC/day
regimen and was not compliant with the treatment with oral antidiabetics. Due to neglected
diabetes at home, the patient’s evolution in the first week was critical with high glycaemic
values and active suppurations from one day to the next, requiring additional incisions both
externally and endoorally. After the glycaemic values below 200 g/dl were successfully
established, the patient’s condition began to stabilize and the drainage tubes were reduced.
Purpose
The purpose of the paper was to highlight patient compliance and cooperation. If the
patient was cooperating from the first presentation in the emergency room, it probably did not
take more than 4 weeks of hospitalization, just as if diabetes was kept under control. The 48
hours that made it impossible to drain the abscess led to at least 20 extra days of
hospitalization due to complications (diabetes).
Result
The patient’s evolution is favourable, after a hospitalization period of 4 weeks.
Conclusion
Delaying the discharge of an abscess, in our case by about 48 hours in an uncooperative

patient with diabetes, led to multiple complications and prolonged hospitalization.
Poor glycaemic control increases the risk of infection, diabetes neuropathy and impaired
innate and adaptive immune responses.
The formation of a multidisciplinary ENT team – oro-maxillo-facial surgery – diabetology
led to favourable results.
REFERENCES
1. Bucur A, Navarro Vila C, Lowry J, Acero J – Compendiu de chirurgie oro-maxilo-faciala, vol. 2, Ed. Q
Med Publishing, Bucuresti, 2009, pp. 241-291.
2. Garbea St, et al., – Chirurgie O.R.L., Ed II, Ed. Didactica si Pedagogica, Bucuresti, 1983, pp. 509-521.
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3. Anniko M, Bernal-Sprekelsen M, Bonkowsky V, Bradley P, Iurato S – European Manual of Medicine,

Otorhinolaryngology, Head and Neck Surgery, Ed. Springer-Verlag Berlin Heidelberg, 2010, pp. 425-
443.
4. Snow JB, Ballenger JJ, et al., – Ballenger’s Otorhinolaryngology Head and Neck Surgery, 16th Edition,
Ed. BC Decker Inc, Hamilton, Ontario, 2003.
5. https://www.revistagalenus.ro/practica-medicala/supuratii-laterocervicale-etiologie-si-tratament/
6. .Ienascu, IMC., Obistioiu, D; Popescu, IM; Stefanut, MN; Gyongyi, O; Jurca, C; Ciavoi, G; Bechir, F;
Cata A In Vitro Testing of Salicylanilide Derivatives Against Some Fungal and Bacterial Strains, Rev
Chem. (Bucarest), 2019, 70(4): pp. 1496-1499.
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Rhinopharyngeal Neoplasm – Distinctiveness of Diagnosis
VETRICEAN Iulia1, GRIGORE Raluca1,3, MUNTEANU Simona-Gloria1,2,3,

BEJENARU Paula-Luiza1,3, CONDEESCU-COJOCARIȚA M.F.1,3,
NITU Liliana1,3, NICOLAESCU A.1, POPESCU B.1,3, MITRAN Denisa Maria1,
POPA Teodora1, MOȘOIU Anca1, OANCEA Alina Lavinia1,3,
OTHMAN A.1, OAȘĂ Irina Doinița1, FLORESCU Elena1,
DIACONU Teodora Elena1, DIMCEA Alisa1, SIREȚEANU Luiza Maria1,
NEDELCU Ruxandra Ioana1, TUDOSIE M.D.1, ENEA A.1,
TEODORESCU-ARGHEZi E.1, ANDRONE Roxana1, MAGDAN M.1,
MIHALCEA C.1, PAVĂL C. C.1, COSTIN R.2, BERTEȘTEANU Ș.V.G.1,3
1 ENT & Head&neck surgery Clinic – Colțea Clinical Hospital, (ROMANIA)
2 ENT & Head&neck surgery Clinic – “Dr. Carol Davila” Central Military Emergency Hospital, (ROMANIA)
3 ENT & Head&neck surgery Department – “Carol Davila” University of Medicine and Pharmacy, (ROMANIA)
4 ENT Clinic – Râmnicu Vâlcea County Emergency Hospital, (ROMANIA)
Email: vetricean@gmail.com
Abstract
Introduction
The rhinopharyngeal neoplasms constitute a group of heterogeneous malign tumours that
are classified according to histological provenience: 70% – rhinopharyngeal carcinoma, 20%
– malign lymphoma and 10% – others (adenocarcinoma, malign melanoma or the metastases
of primary tumours)1. Patients often are absent of symptoms or present non-specific ones
(nasal obstruction, anosmia/hyposmia, epistaxis) that’s why the diagnosis is frequently late.
However, the diagnosis is essential for finding out the type of the tumour furthermore
choosing the right therapeutic strategy.

There were reviewed speciality books and articles describing the methodology of diagnosis
of the rhinopharyngeal neoplasm.
Results
Thorough clinical examination reveals signs and symptoms that are suggestive for the
rhinopharyngeal neoplasm. According to tumour extension, they are classified into initial:
nasal obstruction, oral respiration, anosmia/hiposmia, stand by: cervical adenopathies but
mostly occipital, congestive medium otitis and late ones: epistaxis, ocular globe protrusion,
cranial nerves injure (n. Abducens, n. Oculomotor, n. Trigemen) Serologic tests measuring
the antibodies anti-Epstein Barr titre (tumour marker for undifferentiated and
lymphoepithelial carcinoma) are major for appreciation of the disease prognosis. Computer
tomography of the head neck and thorax is used for evaluation of the tumour extension and
lymph nodes invasion. Rhinopharyngeal biopsy is the gold standard for the final diagnosis but
it’s made only after excluding the rhinopharyngeal angiofibroma (risk of haemorrhage). The
additional diagnosis methods such as PET-CT, abdominal ultrasonography and
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interdisciplinary consults (ophthalmology, neurosurgery) are meant to evaluate the tumour’s

extension and to elaborate a strategy of treatment.
Conclusions
Early diagnosis of the rhinopharyngeal neoplasm is essential for a positive outcome.
Thorough clinical examination sustained by paraclinical investigations allows to evaluate
the type of the tumour, level of extension leading to a correct treatment.
Keywords: rhinopahrynx, neoplasm, diagnosis, Epstein- Barr virus, rhinopharyngeal carcinoma
Introduction
There are several histological types of malign tumours of the rhinopharynx:

nasopharyngeal carcinoma (70%), malignant lymphoma (20%) and a group of very rare
tumours that together represent 10%: adenocarcinoma, adeno-cystic carcinoma,
haemangiopericytoma, osteosarcoma, chondrosarcoma, meningeoma, malignant melanoma,
sarcoma, plasmocytoma, chondroma, metastases of other primary tumours [1].
There were reviewed speciality books and articles describing the methodology of diagnosis
of the rhinopharyngeal neoplasm.
Results
Nasopharyngeal carcinoma (NPC) is a tumour arising from the epithelial cells that cover
the surface and line the nasopharynx. NPC was first described as a separate entity by Regaud
and Schmincke in 1921. Approximately one third of nasopharyngeal carcinomas of the
undifferentiated type are diagnosed in adolescents or young adults. Although rare, NPC
accounts for one third of childhood nasopharyngeal neoplasms. Nasopharyngeal carcinoma
shows a predilection for middle-aged patients however it is also observed in children.
Histologically 50% are keratinizing and non-keratinizing squamous cell carcinomas and
50% undifferentiated carcinomas that in the old nomenclature are called (Schminke-Regaud
tumour) [1, 2].
Infection with Epstein-Barr Virus (EBV) is typical for lymphoepitelial carcinoma.
Histologically, there is a marked preponderance of B lymphocites in which viral antigens
can be demonstrated; they are also found in submucosal glands. The viral antigens expressed
in tumour tissue comprises EBNA1 (Epstein-Barr nuclear antigen) and LMP1 (latent
membrane protein). High antibody titres against many EBV antigens, including lytic viral
antigens, are well recognized and can be clinically used as tumour markers for early diagnosis
and control of tumour recurrence after therapy. In China, consumption of salted fish
containing nitrosamines and smoke from open fires are discussed as additional risk factors
[2]. Clinically there are several symptoms that usually suggest the rhinopharyngeal neoplasm
diagnosis. These symptoms can be classified as initial like cervical lymphadenopathy (Fig. 1,
2) trismus, pain and recurrent epistaxis; stand by – otitis media, nasal regurgitation due to
paresis of the soft palate, anosmia, hiposmia, hearing loss and cranial nerve palsies. Larger
growths may produce nasal obstruction or bleeding and a “nasal twang”. Metastatic spread
may result in bone pain or organ dysfunction. Rarely, a paraneoplastic syndrome of
osteoarthropathy may occur with widespread disease.
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Fig. 1, 2. illustrate the typical cervical adenopathies that occur as an initial symptom
of rhinopharingeal carcinoma
Coronary and axial CT skull, neck show the appraisal of the extent of the tumour (Fig. 3,
4) as well as the involvement of the retropharyngeal lymph nodes involvement CT of the
thorax for the regional metastases. Serological determination of serum antibodies to Epstein-
Barr viruses (virus capsid antigen-IgG and anti-antigen Ig, early antigen, nuclear antigens).
Raised titres are definitive tumour markers in undifferentiated or lymphoepithelial
carcinomas. The titre is important for diagnosis, whereas the time course of titre levels is
crucial in predicting the prognosis.
Fig. 3, 4. represent the cranial CT in transversal and coronal incidences. The

rhinopharyngeal tumour can be observed on the right. Patient has had recurrent nose bleeding and obstruction of
one nostril [6]
Biopsy of the nasopharyngeal tumour in the absence of putative juvenile angiofibroma

(high risk of bleeding) is the gold standard that confirms the diagnosis. An enlarged lymph
node should be totally removed for histological investigation.
Conclusions
Early diagnosis of the rhinopharyngeal neoplasm is essential for a positive outcome.

Thorough clinical examination sustained by paraclinical investigations allows to evaluate
the type of the tumour, level of extension leading to a correct treatment.
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REFERENCES
1. Anniko M., Bernal-Sprekelsen M., Bradley P. – Othorhinolaringology, Head and Neck Surgery pp.
328-330.
polycaprolactone, chitosan and essential oils by: Stoica, Petruta; Chifiriuc, Mariana Carmen; Rapa,
Maria; et al., ROMANIAN BIOTECHNOLOGICAL LETTERS Volume: 20 Issue: 3 Pages: 10521-
10535 Published: MAY-JUN 2015.
https://doi.org/10.1155/2020/3526316.
https://doi.org/10.1007/s10103-019-02934-x.
https://doi.org/10.3892/etm.2019.7857.
doi: 10.3892/etm.2019.7635. Epub 2019 May 31.
2016, Vol. 1 (20), pp. 380-383.
11. Elective Neck Dissection in patients with stage T1-T2N0 carcinoma of the anterior tongue by: Mirea,
12. Brennan, Bernadette (2006-06-26). “Nasopharyngeal carcinoma”. Orphanet Journal of Rare Diseases.
1: 23.
13. Chang, E. T.; Adami, H.-O. (2006). The Enigmatic Epidemiology of Nasopharyngeal Carcinoma”.
Cancer Epidemiology, Biomarkers & Prevention. 15(10): pp. 1765-1777.
14. Petersson BF, Bell D, El-Mofty SK, et al., (2017-01-23). Nasopharyngeal carcinoma: Tumours of the
Nasopharynx, in World Health Organization Classification of Head and Neck Tumours (4th ed.). pp. 65-
70.
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The Experience of Otorhinolaringology Department in Surgical

Treatment of Meniere’s Disease
VETRICEAN Sergiu1, NOROC Iurie2

1,2
(REPUBLIC OF MOLDOVA)
Emails: svetricean@yahoo.com, iurie.noroc@mail.ru
Abstract
Meniere’s disease is an idiopathic disorder, with a great impact on human life, in which
specialists use surgical treatment in order to ameliorate the episodes of vertigo. We have
performed a clinical-statistic study among 23 patients undergoing surgical treatment: chorda
tympani section in Meniere’s disease, in the last 10 years in the Department of
Otorhinolaringology. 1 month postoperatively, 57% of the patients presented the absence of
vertigo episodes, 26% – weaker episodes and 17% – no effect. 12 months postoperatively,
39% of the patients didn’t accuse an exarcebation of the disease, 30% – accused weaker
episodes and 30% – no effect. A correctly indicated surgical operation denotes an 65%
efficiency in the improvement of vertigo episodes in the first year of postoperative evaluation.
Keywords: Meniere’s disease, chorda tympani section, vertigo
Introduction
Meniere disease is an idiopathic disorder, defined by a clinical picture which include acute
episodes of vertigo, fluctuating hearing, tinnitus and a fullness in the ear. The
etiopathogenesis is not completely known. However, it is considered that endolymphatic
hydrops has a major influence in the developing of the disease. The relevance of studying
Menier disease does not decrease in time, because there is no agreement on the ethiology and
pathogenesis. That’s why there is a variety of treatment methods. A certain diagnosis of the
disease is the key to a successful treatment, that will not only eliminate the episodes of
dizziness, but also will stabilize, in some cases, the hearing. The clinical picture of Meniere
disease includes the triad: vertigo, which lasts from several minutes to hours and can be
accompanied by vagal episodes, which can be extremely severe (nausea and vomiting),
unilateral hypoacusis and tinnitus in the same ear.
Meniere disease has an imprevisible evolution with a unilateral debut, becoming bilateral
in time in 50% of the cases (after 2 years-15%, after 10-20 years-30-60%).
In order to find a therapeutic approach, we have researched publications, articles which

highlight the varieties of conservative and surgical therapy. We have analysed the actual
methods of treatment and their benefits in contrast with the old ones, as well as the procedures
used in other countries.
Owing to the fact that, for an objective review of the evolution of surgical treatment, a long
period of observation and an overview of the patient is needed, we have analysed the surgical
treatment of Meniere disease, as well as the long-term results, 5-10-15-20 years.
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We have performed a clinical-statistic study among 23 patients undergoing surgical

treatment for Meniere disease in the last 10 years in the University ORL Clinic IMSP SCR
“Timofei Mosneaga”. The criteria of analysing and studying included: distribution of pations
based on age and gender, disease period, objective clinical examination. After the surgical
intervention performed in Clinic, we have made a postoperative evaluation, in order to
conclude its efficiency.
Results
We have performed a clinical-statistic study among 23 patients, aged between 28-67 years
old, undergoing surgical treatment for Meniere disease in the last 10 years in the University
ORL Clinic IMSP SCR “Timofei Mosneaga”. The criteria of analysing and studying
included: distribution of pations based on age and gender, disease period, objective clinical
examination. The study included 8 men (34,78%) and 15 women (65,22%) aged between 28
and 67 years old. The disease period range between 3 and 5 years-11 patients (47,82%), 6-8
years-9 patients (39.13%), 8-10 years- 3 patients (13,05%). Patients’ acuses were dominated
by the classic triad: episodes of vertigo, tinnitus and hypoacusis (uni- or bilateral). After the
objective structured clinical examination, otoscopic modifications were discovered at 3
patients (13,04%), spontaneous nystagmus in the affected ear at 12 patients (52,17%),
camertonl tests, specific for perception hypoacusis, at 15 patients (65,22%), mixt at 8 patients
(34,78%).
Every patient has undergone chordotomy, plexectomy. Postoperatively, after a month of
satisfactory evolution, 13 patients did not present vertigo episodes, 6 patients presented
weaker and rare episodes, 4 patients- no effect. (Fig. 1.) After 6 months, 15 patients did not
present episodes of vertigo, at 3 patients they were weaker ans rare, and 5 patients- no effect.
(Fig. 2.) In conclusion, after 12 months postoperatively, at 9 patients there were no episodes
of vertigo, 7 patients presented weaker episodes, and 7 patients-no effect. (Fig. 3.)
Fig. 1. Postoperative results (1 month)
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Fig. 2. Postoperative results (6 months)
Fig. 3. Post-operative results (12 months)
Discussion
• Meniere disease is a chronic disease that affects both genders, especially women (8
men-34,78% and 15 women-65,22%).
• The affected age was 28-67 years old.
• The classic triad was present in 100% of the cases. We observe a bilateral damage at
more than 50% of the cases.
• A certain and detailed diagnosis in the early stages of Mediere disease is the key to a
successful treatment.
Conclusions
After a year of postoperatively evaluation, we observe the positive effect of the chosen
procedure:
• The absence of episode at 13 patients (in the first month), at 15 patients (after 6
months), at 9 patients (after 12 months);
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• Weaker and rare episode at 6 patients (in the first month), at 3 patients (after 6
months), at 7 patients (after 12 months);
• No effect at 4 patients (in the first month), at 5 patients (after 6 months), at 7 patients
(after 12 months);
In conclusion, we have an efficiency of 60-70% after performing this procedure, with a
good result in the first year of postoperatively evaluation.
REFERENCES
1. Articol, aspecte vechi utilizate în tratamentul chirurgical în tratamentul maladiei Meniere N.A. Papina,
Catedra Otorinolaringologie, Moscova.
2. Helms J. Neurektomie beim Morbus Meniere. Laryngologie, Rhinologie, otologie, 1977; 56: pp. 417-
420.
3. H.P. Zenner: K + induced motility and depolarization of cochlear hair cells: direct evidence for a new
pathophysiological mechanism and in Meniere’s disease. Arch. Oto-Rhino-Laryngol. 243, 1986.
4. KlocKhoff I, Lindblom U. Menier’s disease and hidroclortiazida (Dichloride): a critical analysis
(symptoms and therapeutic effects), 1969, 312.
5. L. Birgerson, K.H. Gustavson, J. Stahle: Familial Meniere`s disease: a genetic investigation. Am J Otol
8, 1987.
6. Mira E, Guidetti G, Ghiraldi L, Fattori B, Malannino N, Maiolino L si colab. Dihidrocultura de betacina
în tratamentul vertijului vestibular peripheric. Eur Arch Otorhinolaryngol. 2003 februarie 260 (2): pp.
73-7.
7. MG Crowson, A. Patki, DL Tucci. O revizuire sistematică a diureticilor în managemental medical al
bolii Meniere.Chirurgia capului și gâtului (2016), p. 824.
8. MN McDonnell, SL Hillier Reabilitare vestibulara pentru disfuncția vestibulara unilaterală periferică.
Baza de date Cochrane Syst Rev 1 (2015).
9. Moffat DA. Endolymphatic sac surgery: analysis of 100 operations. Clinical Otorinolaringologie Allied
Science. 1994.
10. Pyykko I, Magnusson M, Sehalen L, Enhorn II.Pharmacological treatment of vertigo. Acta
Otorynolaringol (Stockh) 1988: 455:7781.
11. O. Michel: Morbus Meniere und verwandte Gleichgewichtsstörungen 1998.
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Limitations in the Treatment of Bulky Malignant Tumors of the

Parotid Gland – Literature Review, Our Clinical Experience
VRINCEANU Daniela1,3, DUMITRU Mihai1,3, BANICA Bogdan1,

SAJIN Maria2,3
1 ENT Department, Bucharest University Emergency Hospital, Bucharest, (ROMANIA)
2 Head of the Pathological Anatomy Service, Bucharest University Emergency Hospital, Bucharest, (ROMANIA)
3 “Carol Davila” University of Medicine and Pharmacy Bucharest, (ROMANIA)
Emails: vrinceanudana@yahoo.com, orldumitrumihai@yahoo.com, Bogdan.ddr@gmail.com, maria_sajin@yahoo.com
Abstract
Giant tumors of the parotid gland have a long clinical evolution for years, even 15-20
years, and we may wonder how this is possible, why the patient does not come to the doctor.
The answers could be the following: the absence of significant functional deficits, the
aesthetic criterion may not be so important for a certain category of patients, ignorance, fear
of hospital, or even financial constraints. However, the reasons that bring the patient to the
doctor are pain, skin infiltration, and peripheral facial paralysis. Unfortunately, all of these are
signs of malignancy for a benign tumor that has slowly evolved over the years to a point. The
diagnostic algorithm in these cases includes clinical examination, cervical CT/MRI with IV
contrast, Fine Needle Aspiration Cytology (FNAC), extemporaneous histological
examination, paraffin histology, and immunohistochemistry. We will present a review of the
literature and we will make discussions based on clinical experience on limitations in the
treatment of giant malignant tumors of the parotid gland. The conclusion is that an
individualized therapeutic plan is required. Surgical rescue treatment should be done in a
trained mixed team. Adjuvant oncology treatment is essential. Therapeutic success is
measured in years of survival and quality of life.
Keywords: treatment, bulky, malignant tumors, parotid gland, limitations
Introduction
The parotid gland is the largest major salivary gland, and 80% of its tumors are benign
tumors. Of these, about 80% are pleiomorphic adenomas of which 1.4-6.3% become
malignant. A very small number of these become bulky tumors. The literature stipulates a
diameter of more than 10 cm to frame the tumor in giant tumors. The parotid capsule consists
of an inextensible fibrous tissue and maintains the tumor inside the gland for a long time.
Malignancy is associated with capsule burglary and skin invasion. [1]
In the case of bulky tumors, due to the discrepancy between the rhythm of tumor
proliferation versus vascular proliferation, areas of intratumoral necrosis frequently occur,
which gives bulky tumors a polylobate appearance. Intratumoral infarction is secondarily
associated with superinfection and hemorrhage by the detachment of necrotic tumor
fragments by ischemia. In evolution, bulky tumors invade the skin, facial nerve, large vessels
of the neck, in parallel with vascular dissemination and lymphatic dissemination. [2]
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Evaluation of bulky malignant tumors of the parotid gland
These large tumors of the parotid gland have a long clinical evolution for years, even 15-20
years, and we may wonder how this is possible, why the patient does not come to the doctor.
The answers could be the following: the absence of significant functional deficits, the
aesthetic criterion may not be so important for a certain category of patients, ignorance, fear
of hospital, or even financial constraints. However, the reasons that bring the patient to the
doctor are pain, skin infiltration, and peripheral facial paralysis. [3] Unfortunately, these are
signs of malignancy for a benign tumor that has slowly evolved over the years to a point
(Figure 1).
Fig. 1. Bulky pleiomorphic ex-adenoma carcinoma with a course of 20 years in a 68-year-old patient with the
posterior invasion of the skin
Clinical and paraclinical evaluation of a large parotid gland tumor involves a thorough
ENT clinical examination, including laryngeal fiberscopy for intubation, evaluation of the
facial nerve, and other cranial nerves. [4]
The patient almost always has at least one severe peripheral facial paralysis that must be
recorded in medical records. Contrast-enhanced cervical CT examination very well evaluates
tumor extension especially in the parapharyngeal space or in the infratemporal fossa (Figure
2), but cervical MRI is the gold standard for the parotid gland, and gadolinium administration
may reveal invasion of the facial nerve (Figure 3).
A general clinical examination should also be performed to assess possible lesions at a
distance. Bilateral carotid angiography with or without embolization may be useful in
carefully selected cases. The pre-anesthetic examination must assess the conditions for
difficult intubation. Preoperative informed consent must highlight the risk of irreversible
postoperative peripheral facial paralysis in case of the need to sacrifice the facial nerve, as
well as the need for multimodal treatment for therapeutic success. [5]
The diagnostic algorithm in these cases includes clinical examination, cervical CT/MRI
with IV contrast, FNAC, extemporaneous histopathological examination, histopathology, and
immunohistochemistry. [6]
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Fig. 2. Cervical CT with giant left parotid tumor showing anterior displacement of the mandibular branch
and extension into the infratemporal fossa
Fig. 3. Cervical MRI with bulky left parotid tumor with T1 hyper signal marking in two peripheral tumor nuclei
and adjacent skin
Therapeutic principles and limits in giant voluminous malignant tumors of the parotid
gland
Total parotidectomy with preservation of the facial nerve remains the gold standard for
surgery (Figure 4). Facial nerve sacrifice is common in clinical facial paralysis or cystic
adenoid carcinoma even in the absence of clinical facial paralysis.
Other surgical options include enlarged total parotidectomy in the invasion of the skin or
sternocleidomastoid muscle, needlestick removal, plastic surgery of the resulting skin defect.
Essential for therapeutic success is the adjuvant oncological treatment depending on the
paraffin histology and immunohistochemistry – adjuvant radiotherapy or concomitant
radiochemotherapy at positive margins. Histological variants in the case of giant tumors are
the most common ex-adenoma pleiomorphic carcinoma, squamous cell carcinoma, parotid
sarcoma. [7]
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Fig. 4. Intraoperative appearance with tumor infiltrated facial nerve in a case of bulky carcinoma
ex-pleiomorphic adenoma
Limitations in the treatment of large malignant tumors of the parotid gland depend on
several factors. The limits related to the tumor itself are size, mobility, skin infiltration, the
presence of peripheral facial paralysis. [8]
The lack of tumor mobility in the deep planes must weigh heavily in the decision to give
up radical surgery and to be limited to an incisional biopsy (Figure 5) The limits related to the
patient are age, comorbidities, compliance with radical treatment (Figure 6).
Fig. 5. Fixed left giant parotid tumor, no indication for radical surgery, the only indication for incisional biopsy
The limits related to the surgeon are related to the ablative time, which often involves
compromises in the realization of oncological limits. These giant tumors have a long
evolution for years, with the incorporation of vascular and nervous structures, with
perivascular and perineural invasion, so that the negative edges are difficult to obtain.
Reconstructive time can also raise difficulties when extensive skin resections are required.
The limits related to the surgeon are given by the surgeon’s experience and the existence of
a surgical team trained in such surgery to include the ENT surgeon, maxillofacial surgeon,
plastic surgeon, anesthetist, pathologist. The surgery is long-lasting, frequently requiring
reserved blood products, but also intensive postoperative therapy. These interventions are a
test for both the surgeon and the patient. Limits can also be related to the system – a blocked
operating room day, high resource consumption, confusions sometimes generated by the
inconsistency between extemporaneous examination, paraffin examination, and
immunohistochemistry, the timing with adjuvant oncological treatment and oncology
dispensary.
188
©
Fig. 6. Recurrent pleiomorphic ex-adenoma carcinoma with complete right peripheral facial paralysis after 1
year from radical surgery in a non-compliant therapeutic patient who did not follow adjuvant
chemo-radiotherapy and oncology surveying program
The therapeutic indication in bulky malignant tumors of the parotid gland
Given the difficulties related to the sequential therapy of this category of tumors, as well as
the frequent recurrences, we can ask ourselves if these tumors have a surgical indication. Our
experience consists of about 1-2 cases every year in the last 10 years. The existing pieces of
evidence allow us to answer yes to this question, in the absence of the absolute
contraindications represented by the invasion of the internal carotid artery and the invasion of
the last 4 pairs of cranial nerves or the base of the skull. [9]
The surgical indication must be made after a careful cervicofacial clinical examination to
determine the mobility of the tumor at the superficial and deep planes, and the existence of a
whipped peripheral paresis of the facial nerve, careful analysis of cervical CT/MRI, carotid
angiography when we need to objectify the status of the internal carotid artery and we intend
a tumor embolization. Most often the treatment plan must be individualized for each case.
[10]
We need to answer the questions about what ablation entails, what reconstruction entails,
or if lymph node dissection is necessary, and what is proper adjuvant oncological treatment.
We must consider the comorbidities, the patient’s age, and the patient’s compliance in
initiating a therapeutic approach with a high risk of complications and failure.
Conclusions
In bulky malignant tumors of the parotid gland, the most likely therapeutic solution is an
individualized therapeutic plan, made in a mixed team of radiologists, surgeons, anesthetists,
pathologists, radiotherapists, and oncologists. The extemporaneous histopathological
examination is indispensable for the correct management of the margins, and the paraffin
histology and the immunohistochemistry in the sequencing of the therapeutic stages
represented by surgery, radiotherapy, and chemotherapy. Adjuvant cancer treatment should be
considered as having at least equal weight to surgery in terms of chances of cure, and timing
is essential.
Of course, there are limitations related to tumor, patient, surgeon, or system in the
treatment of bulky malignant tumors of the parotid gland, but therapeutic success in oncology
is measured in years of survival and quality of life and these two essential parameters can be
improved by the intervention decision in such cases.
189
©
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Filodiritto Editore – Proceedings

THE NATIONAL ROMANIAN

Log in to find out all the titles of our catalogue

First Edition March 2021

© Copyright 2021 Filodiritto Publisher

Quality of Life after Organ Preserving Techniques in Treatment of Laryngeal Cancer 11

A 3-year-old Boy Burkitt’s Lymphoma Enhancing Otomastoiditis with Facial Palsy 19

A Rare Case of Mucosal Melanoma of the Nasal Cavities 25

Endoscopic Approach of the Frontal Sinus – Anatomical References. Article Review 27

Fungal Rhinosinusitis – Diagnostic Aspects, Evolution, Prognosis and Treatment 32

Salvage Surgery in Advanced Temporal Region Cancers 38

Epidemiological, Clinical and Therapeutic Aspects in Odontogenous Sinusitis 45

Flexible Endoscopic Surgery for Glottic Carcinoma in a Patient with

Universal New-born Hearing Screening: The Experience of Children’s Clinical

Borderline Frontal and Ethmoid Osteoma – Full Endoscopic Approach 63

Nasal Wing Foreign Body. Case Report 68

Functional Results of Tympanoplasty with Partial Mastoid Obliteration Due to

A Particular Clinical Case of Dysphagia in Children 81

Case Report: Laterocervical Adenophlegmon in Children 84

Larynx Papilomatosis-Diagnosis and Treatment 88

Paragangliomas – Therapeutic Management – Review 94

Laryngological Aspects in SARS-CoV-2 Infection 107

Implication of Cumarinic Overdosage in the ENT Sphere 117

B-Cell Lymphoma of the Sinus Cavities, Case Report 120

Laryngeal Angioedema by Acquired C1 Inhibitor Esterase Deficiency, Case Report 127

Surgical Reconstruction Methods for Head and Neck Skin Defects

Hearing Impairment in Patients with Cholesteatoma 138

ENT Manifestations in Systemic Diseases 149

Major Reconstruction Following Salvage Laryngectomy – Case Report 154

A Rare Case of Parotid Gland Teratoma in a 3 Months Old Patient 158

Features in HPV Positive Oropharyngeal Cancer 163

Tracheo-bronchial Foreign Bodies in Tracheostomized Patients. A Review of

Submandibular Abscess of Dental Origin and Its Evolution, in Immunosuppressed

Rhinopharyngeal Neoplasm – Distinctiveness of Diagnosis 177

The Experience of Otorhinolaringology Department in Surgical Treatment

Limitations in the Treatment of Bulky Malignant Tumours of the Parotid Gland

Quality of Life After Organ Preserving Techniques in Treatment

BEJENARU Paula Luiza1,2, GRIGORE Raluca1,2, NIȚU Liliana1,2,

Emails: drpaulabejenaru@gmail.com, berstein@dr.com

Materials and methods

Material and methods

Retrospective, descriptive study of 40 cases – patients who were admitted to Coltea

Supracricoid partial laryngectomies with variation of reconstruction

1. Available https://www.who.int/tools/whoqol; Accessed 07.02.2021

A 3-year-old Boy Burkitt’s Lymphoma Enhancing Otomastoiditis

BULMACI Mara1,2, DINDELEGAN Maximilian George1,2,

Burkitt Lymphoma (BL) refers to a high-grade B-cell non-Hodgkin lymphoma

Fig. 2. Cerebral MRI – multiple poorly Fig. 3. Contrast-enhanced chest CT –

Particularity of the case

Three types of BL can be distinguished: sporadic, endemic (African), and

Table 1. Otorhinolaryngologycal presentations of Burkitt’s lymphoma

Waldeyer ring involvement Tonsil mass; sore throat

Nose involvement Nasal obstruction, rhinorrea, anosmia, nose bleeding

Maxillary, spheno-etmoidal pain, rhinorhhea, facial pain, facial

Oral cavity Gingival infiltration and bleeding

Tongue Difficulty in swallowing, tongue mass

Parapharyngeal space Difficulty in swallowing, reduced hearing, headache

Larynx Dyspnea, stridor, hoarsness

A Rare Case of Mucosal Melanoma of the Nasal Cavities

CHIOREANU Alexandru1, BAȘCHIR Sorin1, MORAR Raluca2,

Mucosal malignant melanomas present symptoms such as progressive nasal obstruction,

Endoscopic Approach of the Frontal Sinus – Anatomical