E-ISSN 2602-4837
The Turkish Journal of Ear Nose and Throat - Tr-ENT: 19 (4)
Volume: 19  Issue: 4 - 2009
ORIGINAL ARTICLE
1.Differential diagnosis in cervical lymphadenopathies: efficacy of B-mode, color and power Doppler ultrasonography
Ziver Ayata, Melda Apaydın, Makbule Varer, Ayşegül Sarsılmaz, Çağlar Çall,, Türkan Rezanko
Pages 173 - 178
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Objectives: Our purpose was to investigate cervical lymphadenopathies
by using color Doppler spectral analysis and power Doppler
ultrasonography methods as well as B-mode ultrasound and to classify
them as malignant or benign lesions and to compare the results
with the histopathological findings.
Patients and Methods: Sixty nine lymph nodes of 69 patients were
evaluated with color and power Doppler ultrasonography as well as
B-mode ultrasonography. The shape and dimensions of the lymph
nodes were assessed with B-mode ultrasonography; their vascularization
pattern with power Doppler sonography and with color Doppler
spectral analysis. Vascular pattern was evaluated according to the
vascularization of the lymph node. Vascular resistive index and pulsatility
index were assessed by at least three flow samplings. We measured
resistive index, pulsatility index, peak systolic velocity, and end diastolic
velocity. Results of Doppler analysis were compared with clinical findings
and histopathologic results. Nodes were grouped as metastasis,
lymphoma, tuberculosis, and reactive benign lymphadenopathies with
respect to ultrasonographic results.
Results: Forty four of 69 lymph nodes were found to be malignant
histopathologically. In color Doppler analysis, most malign metastatic
lymphadenopathies showed peripheral (76.4%), and the rest of them
(23.6%) showed peripheral and hilar (mix) vascularization. Most
benign lymphadenopathies (88%) and lymphomatous lymphadenopathies
(85%) had hilar vascularization. In tuberculous lymphadenopathies,
50% of them showed avascular pattern and the rest of them
had variable type of vascularization. A resistive index greater than

0.7 indicated a malignant metastatic lymphadenopathy and a resistive
index <0.5 was consistent with benign lesions. In lymphomatous
and tuberculous lymphadenopathies resistive index values were
between 0.6-0.7. The sensitivity of the resistive index for distinguishing
inflammatory from neoplastic lymphadenopathies was 84.6%, the
specificity 100% and the diagnostic accuracy 95.7% (p<0.001).
Conclusion: In addition to B-mode ultrasonography findings, vascularity
pattern assessment and spectral analytilic measurements with color
and power Doppler ultrasonography has an important contribution for
the differential diagnosis of cervical lympadenopathies.

2.The comparison of the expansion of polyps according to the Ki-67 and computed tomography scores
Sedat Aydın, Arif Şanlı, İlter Tezer, Ümit Hardal, Nagehan Özdemir Barışık
Pages 179 - 183
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Objectives: The disease extention in nasal polyps
was compared by using the mitotic activity rates and
the computed tomography scores.
Patients and Methods: This study was conducted on
19 nasal polyposis patients (8 males, 11 females; mean
age 40.0±13.7 years; range 20 to 63 years). The preoperative
computed tomography records of the patients
were evaluated according to the Lund-Mackay grading
system. The polyp tissues of the same patients were
stained with the Ki-67 antigen for immunohistochemical
evaluation. The correlation between the radiologic
results and the Ki-67 values was compared by means
of the Spearman’s correlation test.
Results: The mean computed tomography score
was observed as 14.3±4.7 (range 7-24). The mean
Ki-67 score resulting from the immunohistochemical
staining was calculated as 24.3±18.5 (range
%3.3-73.5). A significant correlation was determined
between the Ki-67 values and the computed
tomography scores. (“Spearman’s” correlation factor:
0.677; p<0.001).
Conclusion: As the mitotic activity rate of nasal polyps
increases, both the volume of the polyps and the
computed tomography scores increase as a result of
the blockage of the sinus ostiums by the increased
polyp volume.

3.Preoperative evaluation of chronic rhinosinusitis patients by conventional radiographies, computed tomography and nasal endoscopy
Fikret Kasapoğlu, Selçuk Onart, Oğuz Basut
Pages 184 - 191
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Objectives: The aim of this study was to compare the efficacy of
conventional radiography (CR), computed tomography (CT) and nasal
endoscopy for the preoperative evaluation of chronic rhinosinusitis in
patients with persistent complaints despite appropriate medical therapy.
Patients and Methods: Forty-three patients (26 males, 17 females;
mean age 43 years; range 15 to 73 years) were prospectively evaluated.
All patients underwent detailed physical examination, CR and
coronal high resolution CT of paranasal sinuses. Thirty of them were
evaluated with detailed nasal rigid and/or flexible endoscopy as well.
The anatomic variations and mucosal changes in paranasal sinuses
were noted. The specificity and sensitivity of CR was calculated
using CT findings as a reference point. Surgery was performed on
two of the other three patients because of obstructive symptoms of
middle turbinate. Paradoxal middle turbinate surgery was performed
on one patient due to a headache of rhinogenic origin.
Results: In our study 40 (93%) of all patients showed mucosal
abnormalities on CT. Computed tomography scanning of the patients
revealed anatomic variations in 74.4% of the cases. Mucosal pathology
was most frequently observed in the anterior ethmoid region
(middle meatus). While we found mucosal anomalies in 47.4% of all
sinuses using CR, 42.2% of these cases were confirmed with CT.
Also, 19.5% of all sinuses evaluated as normal with CR presented
pathologic findings on CT. An overall correlation of 75.3% was
observed between CR and CT, while diagnostic nasal endoscopy
and CT findings were correlated at a rate of 87%.
Conclusion: (i) While no ipsilateral maxillary or frontal sinus disease
was detected when no abnormality in the anterior ethmoid region and
infundibulum was observed endoscopically in the presence of mucosal
abnormalities similar abnormalities were seen at the same side for maxillary
or frontal sinuses. (ii) Anatomic variations of nasal and paranasal
sinuses may be considered as etiologic and predisposing factors of
chronic rhinosinusitis. (iii) Conventional radiography should not be used
as a single diagnostic tool in pre-operative evaluation; however, due to
its high sensitivity, CR technique may be used alone in the diagnosis
and follow-up of maxillary sinus disease. (iv) Nasal endoscopy may
reduce unnecessary diagnostic CT scanning procedures.

4.The therapeutic role and effectiveness of selective neck dissection in the management of N0 neck
Fulya Özer, Cem Özer, Alper Nabi Erkan, Haluk Yavuz
Pages 192 - 197
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Objectives: To assess the therapeutic role and the effectiveness
of the selective neck dissection in the management
of the clinically node negative neck in the head and neck
squamous cell carcinomas.
Patients and Methods: The charts of 177 patients with
squamous cell carcinoma, who underwent neck dissection
between January 2000 and January 2007, were reviewed
retrospectively. Seventy neck dissections in 58 patients (51
males, 7 females; mean age 63 years; range 21 to 85 years)
in whom the primary site of the lesion was the larynx, oral cavity,
oropharynx and hypopharynx, and who were considered
to have N0 neck and to comply with the study criteria were
included in the study. Details were collected on tumor site and
stage, type of surgery, pathologic N stage, number and size of
pathologic nodes, extracapsular spread of nodes, postoperative
radiotherapy, local recurrence, follow up time and survival
status in all patients.
Results: It was found out that selective neck dissection
operations were performed on 99 of 102 N0 patients. The
follow up time was approximately 23 months in 58 patients
who who were found to comply with the inclusion criteria.
The most frequent site for primary tumor was larynx and most
patients were at T2 stage. Nine patients had pathologically
positive lymph node with occult metastasis rate of 13%. The
overall recurrence rate was 19%. Postoperative radiotherapy
was used as adjuvant therapy in 15 patients. Regional control
rate was lower in patients with pathologically positive lymph
nodes. However, it was not statistically significant.
Conclusion: Selective neck dissection is an effective and
safe method for controlling and staging of the patients with
clinically N0 neck.

5.Effectiveness of voice therapy in hyperfunctional dysphonia in adult patients
Tolga Kandoğan, Murat Koç, Gökçe Aksoy
Pages 198 - 202
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Objectives: In this retrospective study, voice therapy
results of adult patients with hyperfunctional voice
disorders were discussed.
Patients and Methods: Ninety-one adult patients (59
females, 32 males; mean age: 37 years; range 18 to
54 years) who completed their voice therapy sessions
between May 2002 and May 2007 were included in
this study. The voice therapy plan was focused on
developing competence in perception, tonus regulation,
physiological breathing and physiological use of
voice. Especially Koblenzer, Smith, Fröschels, Höller-
Zangenfeind and Pahn techniques were included in the
plan. Patients had voice therapy sessions every one
or two weeks for about 30-45 minutes. On average,
patients had eight sessions. Voice therapy was conducted
by the same voice therapy team to the patients.
Vocal use and hygiene guidelines were also explained
to the patients. In the objective and subjective evaluation
of voice, disphonia severity index (DSI) and voice
handicap index (VHI) scores were used respectively.
Results: After voice therapy, DSI increased from
–1.4 to 1.1 and VHI decreased from 72 to 43. Voice
therapy was found to be succesful clinically.
Conclusion: These results suggest that patients
withhyperfunctional voice disorder benefits fromvoice
therapy.

CASE REPORTS
6.Tonsillolithiasis with actinomycotic infection: a case report
Emel Çadallı Tatar, Mahmut Karaçay, Güleser Saylam, Hakan Korkmaz, Ali Özdek
Pages 203 - 206
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Tonsillar calcifications, tonsilloliths, are not rare
conditions for routine ear nose throat examinations.
Their size vary from barely visible to the pea size
and they should be kept in mind in the differential
diagnoses of radiopaque lesions in this region. We
report a 42-year-old male patient who had a large
tonsillolith together with an actinomycotic infection
of tonsillar region. The patient complained about
recurrent tonsillar infections. In his routine ear nose
throat examination a large tonsillolith, lodged in
the right palatine tonsil, was observed. The patient
underwent tonsillectomy under general anesthesia.
Histopathologic evaluation confirmed the diagnosis
of tonsillolith. Interestingly, actinomycotic infection
was observed. The pathogenesis of tonsilloliths is
not completely defined. Many investigators have
suggested that tonsilolliths originate as a result
of recurrent tonsillar infections. Our purpose is to
remind the tonsillolith in the differential diagnoses of
chronic tonsillar region pathologies.

7.Lipoma of the cerebellopontine angle: two cases report and review of literature
Nazım Korkut, Hüseyin Işıldak, Kemal Tuskan, Şahin Öğreden
Pages 207 - 211
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Here we report two cases with cerebellopontine
angle lipoma. Cerebellopontine angle lipomas
previously reported in the literature were reviewed.
The review of the literature revealed the condition
is more prevalent in women. The median tumor
size was 10.26 (range: 1 to 26) mm. It was noted
that these tumors are most frequently associated
with hearing loss (56%) and tinnitus (40%), while
9% demonstrate no symptoms. Fifty-six percent
of these patients had been operated, however
complete resection had been accomplished in
only 36% of patients. In our cases, the tumor
sizes were 7x4 and 5x3 mm. Tinnitus and ear fullness
were major complaints in both cases. One
case had hearing loss and vertigo in addition to
these complaints. Surgery was not performed for
these cases. The patients have been followed up
using same approach without any complication.
Histopathological diagnosis is rarely necessary
with the widespread use of magnetic resonance
imaging. Because of the potential for significant
morbidity with resection of these lesions, conservative
follow-up is the best approach for cerebellopontine
angle lipoma.

8.A rare vascular tumor of the external auditory canal: the capillary hemangioma
Hüsamettin Yaşar, Haluk Özkul, Adnan Somay
Pages 212 - 215
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A 32-year-old woman presented to our department
with a 10-month history of right-sided intermittant otorrhagia.
There was no history of hearing loss or pulsatile
tinnitus. Otomicroscopic examination revealed
a reddish mass arising from the right antero-superior
portion of bony canal wall, which measured about
1 cm in diameter. The tympanic membrane seemed
to be uninvolved. A computed tomography scan of
the temporal bone showed 0.6x0.8 cm diameter softtissue
mass arising from the right external auditory
canal, 0.5 cm away from tympanic membrane. The
lesion was excised via a transcanal approach under
local anesthesia. The histopathologic assessment
indicated a capillary hemangioma. There was no
recurrence four years after the surgery. Hemangioma
of the external auditory canal is a rare otologic entity.
It is commonly classified as capillary or cavernous
hemangioma. According to the literature, this case
represents the second patient with capillary hemangioma
of the external auditory canal.

9.An unusual giant subacute necrotizing sialadenitis as an emergency case of otolaryngology
Ahmet Eyibilen, Nilüfer Çakır Özkan, İbrahim Aladağ, Fatih Özkan, Ziya Kaya, Doğan Köseoğlu
Pages 216 - 219
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Subacute necrotizing sialadenitis is an inflammatory
necrotizing lesion occurring in minor salivary glands.
Most cases occur in the palatal region. In this article,
we reported a 36-year-old man referred to our clinic as
an emergency with the complaints of excessive bleeding,
airway obstruction and hipovolemia. Intraorally,
there was a hemorrhagic, protruding giant mass in
the palatal region. Following the first biopsy, which
was not diagnostic, a second biopsy was performed.
Histopathologic examination showed acinar cell necrosis
and dense inflammation of the affected minor
salivary glands in the second biopsy. The diagnosis
of subacute necrotizing sialadenitis was made on the
basis of clinical and histologic features of the lesion.
Subacute necrotizing sialadenitis is a rare lesion, and
admittance to the otolaryngology clinic as an emergency
case is much rarer. To avoid unnecessary surgical
intervention, it is necessary to diagnose subacute
necrotizing sialadenitis correctly, which can be confused
with malignant diseases of the salivary glands.

10.Infraorbitally located tuberculous lypmhadenitis: a case report
Ümit Hardal, Gökhan Altın, Mustafa Paksoy, Sedat Aydın, Alev Oktay
Pages 220 - 223
Tuberculosis, which is one of the oldest diseases
of the human kind, is again becoming an important
health issue in recent years. Although mostly seen
in lungs, it can also be localized in the lymph nodes,
skin, meninges, spleen, surrenal tissues, which is
referred to as extrapulmonary forms of tuberculosis.
Tuberculous lymphadenitis is the most common
clinical form of extrapulmonary tuberculosis and it
is generally localized in cervical lymph nodes. A
50-year-old female patient presented with a hard
fixed mass originating from medial cantus ending at
nasobial sulcus. In the magnetic rezonance imaging
examination, a solid contrast enhancing mass
20x18x15 mm in size, which was isointensely monitored
with muscular structures in T1 based visuals
and hyperintense in T2 sequences, was seen. The
mass was excised under general anesthesia and
histopathological examination revealed tuberculous
lymphadenitis. Thus, the case is discussed according
to literature and shows us that tuberculosis may
be the reason for lymphadenitis in the areas out of
the cervical region and it should always be kept in
mind in the differential diagnosis.

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