Expression of tumor necrosis factor Alpha, interleukin-1 and matrix metalloproteinase-9 and pathomorphological changes in acquired middle ear cholesteatoma

Introduction. The inflammatory mediators play a central role in the pathogenesis of the inflammatory process of the middle ear and cholesteatoma from the aspect of initiating and maintaining the inflammatory response to infection and lesion. The aim of the study was to examine if the presence of acquired cholesteatoma could predict pathomorphological changes of the tympanic cavity mucosa in relation to the control tissue of the inflamed middle ear mucosa and to examine and compare the expression levels of tumor necrosis factor-alpha (TNF-a), interleukin-1 (IL-1) and matrix metalloproteinase 9 (MMP-9) with pathomorphological changes in the middle ear mucosa in chronic otitis media (COM), with and without acquired cholesteatoma (AC). Methods. The immunohistochemical study included 178 patients of both sexes, aged 5 to 75, who underwent microsurgical treatment of COM from 2015 to 2018. Patients were divided into two groups based on the presence or absence of AC of the middle ear: 97 with cholesteatoma (CCOM) and 81 without cholesteatoma (COM). Samples of the perimatrix of AC and inflamed middle ear mucosa were taken intraoperatively. The condition of the tympanic cavity mucosa was examined by otomicroscopy exploration intraoperatively. The expression levels of TNF-a, IL-1 and MMP-9 were determined by immunohistochemical analysis. Results. The difference in the percentage distribution of patients according to the condition of the tympanic cavity mucosa between both groups was statistically significant (p <0.01) where in the COM group the highest frequency was 43.2% of patients with mucosal hypertrophy, and in the CCOM 56.7% with granulations. With highly positive expression of TNF-R2 and IL-1, a higher probability of the presence of mucosal hypertrophy and granulations can be expected, and with highly positive expression of MMP-9 the presence of granulations. Conclusion. Acquired middle ear cholesteatoma is a statistically significant predictor of the occurence of mucosal hypertrophy and granulations in the tympanic cavity in relation to the control tissue of the inflamed middle ear mucosa. The high expression of TNF-R2, IL-1 and MMP-9 shows a statistically significant association with the presence of granulations and mucosal hypertrophy in acquired middle ear cholesteatoma which may have clinical significance in the evaluation and prognosis of the disease.

Evaluation of Recurrent Maxillary Sinusitis due to Middle Meatal Antrostomy Site Stenosis

Objective: This study was performed to evaluate the incidence, timing, and factors contributing to recurrent maxillary sinusitis due to middle meatal antrostomy (MMA) site stenosis after endoscopic sinus surgery (ESS). Methods: The medical records and endoscopic photographs of 288 patients with chronic rhinosinusitis who underwent ESS were evaluated. Patients visited the clinic with similar schedule after ESS; recurrent maxillary sinusitis due to MMA site stenosis was investigated, including in terms of the incidence and timing. The preoperative computed tomography (CT) scans, intraoperative findings, and possible factors contributing to MMA site stenosis were examined. Results: Recurrent maxillary sinusitis due to MMA site stenosis occurred in 10 patients. Most had unilateral sinusitis and stenosis was observed within 6 months postoperatively. All patients had severe inflammation, pus retention, and thick mucosal hypertrophy in the maxillary sinus on preoperative CT; intraoperative findings confirmed these conditions. In most patients, extensive trimming of the hypertrophied mucosa was performed intraoperatively through canine fossa trephination. Conclusions: MMA site stenosis is a rare condition after ESS. We hypothesized that rapid shrinkage and fibrosis of the sinus mucosa after extensive trimming thereof may be the main causes of stenosis. Residual mucosal inflammation, granulation formation, and persistent sinus crust and debris may also be contributing factors. Therefore, conservative trimming, meticulous dressing, and removal of sinus crust and granulation tissue near the MMA site should be performed in patients with MMA site stenosis.

Facial Nerve Paralysis in a 54-Year-Old Woman with Exacerbated Chronic Suppurative Otitis Media and Chronic Mastoiditis: A Case Report

We present the case of a 54-year old woman diagnosed with chronic suppurative otitis media, who was admitted to the ENT Department with four-week-old, sudden-onset, left-sided facial nerve paralysis, and ipsilateral otalgia and hemicrania. Physical examination revealed positive signs of acute postaural inflammation. The patient’s facial nerve paralysis was scored as VI, according to the House-Brackmann scale. A cranio-facial computer tomography examination revealed mastoid cavity opacification, mucosal hypertrophy, and signs of chronic osteitis, with minimal mucous accumulation. The patient underwent a radical modified mastoidectomy with type-I tympanoplasty to verify the presence of a cholesteatoma, and to remove the offending lesions. Post-operatively, patient evolution was favorable, and prognosis remained encouraging. The patient’s evolution will be followed by check-ups every three months to assess progress and benefits of the treatment.

Transnasal endoscopy – Evaluation and treatment method for patients with sinus lift and dental implants indications

BACKGORUND. Sinus floor elevation, also known as sinus lift, is the surgical procedure meant to elevate the maxillary floor in order to increase the height of the alveolar bone. This will allow the oral surgeon specialist to insert the desired implants, the ground of dental reconstruction. As the procedure involves the maxillary sinus and its Schneiderian membrane the main concern is to have a healthy maxillary sinus prior to implantation and to the maxillary augmentation. OBJECTIVE. The aim of our study was to identify the patients with abnormal CT scan and refer them to an ENT evaluation, in order to identify and treat any sinusal pathology that can lead to a poor outcome of the sinus-lift intervention. MATERIAL AND METHODS. Our prospective study included 15 patients selected from a group of 79 adults, candidates for dental implantation with sinus augmentation. These patients had abnormal sinus CT scan in terms of mucosal hypertrophy, cysts or fungal material. Transnasal diameatic sinusoscopy was performed for all the patients, assessing the aspect of the sinus cavity and the mucosa. The following abnormal aspects were found in our group: 5 patients with cysts, 2 patients with fungus ball and 4 with mucosal hypertrophy. 4 patients had normal maxillary mucosa despite the CT scan appearance. RESULTS. All the patients with abnormal aspects at sinusoscopy (11 patients) were operated on before sinus lift procedure - antrostomy, cyst removal, fungus ball removal. 4 patients showed normal aspect of the sinus mucosa despite the CT scan donations, meaning a 26.66% error rate in appreciating the real changes of the maxillary mucosa on the CT scan. CONCLUSION. Endoscopic assessment of the maxillary sinus is mandatory in patients with changes of the CT scan. This allows a proper examination of the sinus mucosa and can predict the outcomes of the sinus lift procedures. It is mandatory to cure the inflammation or infection of the maxillary sinus prior to implant procedure in order to be able to increase the success rate, as it can lead to failures of the implant procedure.

A Case Report of Malignant Melanoma of the Sphenoid Sinus

Malignant melanoma of the sphenoid sinus is a very rare disease, and only 6 cases have previously been reported. The present case involved a 74-year-old woman who was examined for visual disturbance of the left eye. Computed tomography revealed a soft tissue shadow, but only mucosal hypertrophy was found on opening the sphenoid sinus under general anesthesia. One month postoperatively, visual disturbance of the right eye and paresis of cranial nerve III appeared. Malignant melanoma was diagnosed from biopsy. Multiple bone metastases were identified, but the patient declined active treatment. As a result, palliative care was provided and she died 3 months later. When there is no improvement in postoperative visual acuity as in this case, in consideration of the possibility of neoplastic lesions, rigorous followup including monitoring for neurological symptoms is warranted.