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SUBACUTE THYROIDITIS AND BACTERIAL PHARYNGITIS, CASE REPORT Kuci Anjeza, ENT, Main Policlinic of the Specialties NR.3, Tirana, Albania Golemi Ersida, Main Policlinic of the Specialties Nr.3, Tirana, Albania BOCI BESIM, Prof. Ass., Head of ENT Department, Mother Teresa Hospital, Tirana, Albania Introduction: De Quervain Subacut thyroiditis is an autoimmune inflammatory disease of the thyroid glandule probably with a viral origin. Itâ&#x20AC;&#x2122;s the most common complain of the anterior sore throat. Itâ&#x20AC;&#x2122;s more frequent in females from 30-60 years old. Bacterial pharyngitis is a common infection in children and more rare in adults. Most of the cases we find a streptococcal infection with high level of ASLO. Subacute pharyngitis is presented with prodromal sign of viral infection and bacterial pharyngitis with high temperature, difficulty in swallowing, headache, frisone etc. Case report: Female, A.B, 43 years old presented with sore throat from 2 weeks which is irradiated in the ear and the anterior part of the neck .It has begun 2 weeks after a VIRT. The pain is increased during coughing and eating.. Other complains are palpitations, diaphoresis, nervosity, muscle weakness. Echo of the thyroid: diffuse hypoechogen areas with a swollen painful thyroid in palpitation. FT4= 34.1 pg/ml (7-18) , FT3=5.2 pg/ml (24.2), TSH=0.01 m UI/ ml (0.17-4.04). Diagnosis: Subacute Thyroiditis. The patient began the treatment with cortisone. After 2 weeks from the beginning of the cortisone therapy the patient had the same symptoms: pain in the neck, high temperature, muscle weakness directly after decreasing the dose of the cortisone. We doubted of bacterial pharyngitis after the clinical examination of cavum oris and cervical lymphadenopathy in neck palpitation. We found le=11.500 Ui/l and ERS=55 mm/hourly, PCR=55(under 5). We found positive Strep test and ASLO=500 UI(< 250UI). This was a case of subacute viral thyroiditis complicated with Bacterial pharyngitis. We initiate the antibiotic therapy for 10 days, analgesics, antipyretics and continued the cortisone therapy for 2 months. After 2 months the patient was completely cured.

HOT LINGUAL THYROID KUCI Anjeza, ENT, MD, Center Policlinic of the Specialties, Nr.3, Tirana, Albania GOLEMI Ersida, Endocrinologist, MD, Center Policlinic of the Specialties, Nr.3, Tirana, Albania BOCI BESIM, Prof. Ass., Head of ENT Department, Mother Teresa Hospital, Tirana, Albania Introduction: Lingual thyroid or ectopic thyroid is defined as the presence of the thyroid tissue in the midline at the base of the tongues anywhere between the circumvallate


papillae and the epiglottis. It is a rare anomaly with a reported incidence 1:3000 of the thyroid cases seen with overall prevalence of 1 in 100.000. Other sides of local thyroid deposition include the cervical lymph nodes, submandibular glands and the trachea. Diagnosis of lingual thyroid is usually made clinically and radionuclide scanning is used to confirm the diagnosis. Case report: male, A.D., presented with history of dysphagia, foreign body sensation, dysphonia as well as palpitations, heat intolerance, diaphoresis, easy fatigability and has fine hand tremors. In the oropharinxoscopy examination we found normal examination of the cavum oris, palatum, uvula, and pharynx. At the base of the tongue in laryngoscopy we saw a fleshy erythematous swelling that moves with tongue protrusion that differs a lot from lingual papillae. We performed an ultrasonography of the neck that reveled non visualization of the thyroid in its normal anatomic location. TSH levels was low 0.01 uIU/ml ( 0.1-4), FT4 was high 32 ng/ml( 8-18), other chemical parameters were normal. Radionuclide scan with 99 mTc reveled the location of the ectopic thyroid. We confirmed the diagnose: Lingual thyroid with hyperthyroidism. We initiate the treatment with ATS (Methymasole) to stabilize the level of thyroid hormones for 3 weeks. We stabilize the thyroid hormones levels and performed the total ectopic thyroidectomy. The biopsy resulted negative for malignancy. After the surgery we initiate the treatment with levothyroxine.

NATURAL LOOK OF THE NASAL DORSUM WITH OVERLAY CONTAINING CARTILAGE PASTE AND A-PRF AND I-PRF IN RHINOPLASTY Assen Assenov1,2, Bozhidar Mitev1,2 1University 2Medical

Hospital UMHAT Plovdiv, Department of ENT, Plovdiv, Bulgaria

University Plovdiv, Department of ENT, Plovdiv, Bulgaria

Rhinoplasty is the most common cosmetic surgery procedure for correcting and reconstructing the form, restoring the functions and aesthetically enhancing the nose. The nasal dorsum plays significant role in the aesthetic evaluation of the nose and the face as a whole. We report the use of cartilage paste embedded in an autologous Advanced Platelet Rich Fibrin (A-PRF) and Injectable Platelet Rich Fibrin (i-PRF). This construct is placed on the nasal dorsum as an overlay and is gently moulded according to the characteristics of each patient's face. When delicately pressed between two gauzes, the A-PRF clot becomes a strong membrane with which we cover cartilage paste fixated with I-PRF. This method can be considered an alternative not only to smoothen irregularities of the nasal dorsum, but


also to augment nasal dorsum. This overlay containing PRF releases gradually and growth factors or cytokines in the site. The expected objective of these growth factors is to accelerate the soft tissue and bone healing. Based on our preliminary results, cartilage paste in PRF appear to be a promising and reliable technique to smoothen irregularities of the nasal dorsum, but long-term effectiveness continues to be the main topic of discussion.

THE EFFECT OF SEPTOPLASTY ON DIMENTIONS OF THE COMPENSATORY HYPERTROPHY MIDDLE TURBINATE Authors: Deniz Demir1, Mehmet Güven1, Kıyasettin Asil2 The objective was to measure the dimensions of the compensatory hypertrophy middle turbinate in patients with nasal septal deviation before and after septoplasty and investigate whether the effect of the compensatory turbinate on sinus dysfunction. A retrospective chart review We examined 40 patients with nasal septal deviation. The mucosal and bone structures of the middle turbinate and the angle of the septum were measured using radiological analysis before the operations and at least one year after the operations. On the postoperative images, all sinuses on the concave side of the septum were detected separately for the presence of mucosal disease. All measurements of the middle turbinate before and after septoplasty were compared using two paired sample t test and Wilcoxon rank sum test. Results: The dimensions of bony and mucosal components of the middle turbinate on concave and convex sides of the septum were not significantly changed by septoplasty. There was a statistically significant a correlation after septoplasty between the angle of the septum and convex side of middle turbinate total area (p=0.033). We could not notice any mucosal diseases on concave side of all images after a year. The present study findings suggest that the compensatory hypertrophic middle turbinate may not be affected by septoplasty even a year. We identified that this hypertrophy does not induce any sinus dysfunction on concave side of the septum.

DO PRETREATMENT HEMATOLOGIC PARAMETERS AFFECT THE RECOVERY TIME OF BELL’S PALSY IN PATIENTS WITH COMORBID DISEASE? Deniz Demir1, Sena Genç1, Mehmet Güven1, Mahmut Sinan Yılmaz1, Ahmet Kara1 This study investigated the effect of hematologic parameters on prognosis of Bell’s palsy in patients with comorbid disease.


Materials and Methods: A single-center retrospective study was conducted. Sixty patients with comorbid diseases diagnosed with Bell’s palsy received intratympanic steroid injections. Examination based on the House Brackmann (H-B) grading system was done for up to 6 months or until complete recovery from Bell’s palsy. Hematologic and baseline characteristic parameters were analyzed to investigate a relationship with the complete recovery time from Bell’s palsy. There were a total of 60 patients consisting of 34 (56.7%) males and 26 (43.3%) females in the study. The median age of the patients was 49 years (IQR 43.5-55). In terms of comorbid diseases, the distribution of patients was DM 16 (26.7%), HTM 25 (41.6%) and both DM and HTM 19 (31.7%) Lymphocyte and neutrophil values were significantly associated with the complete recovery time from BP (respectively, p=0.046, p=0.007). The hematologic values could be useful as inflammatory markers in clinical practice and for predicting Bell’s palsy prognosis.

ANAESTHETIC MANAGEMENT OF LARYNGEAL OBSTRUCTION Marinov Ts.1, M. Belitova1, T. Popov2, D. Konov2, M. Tsekova-Chernopolska2 1Department

of Anesthesiology and Intensive Care; University Hospital “Queen Giovanna”ISUL; Medical University-Sofia 2Department

of ENT Surgery; University Hospital “Queen Giovanna”- ISUL; Medical University-Sofia Theoretical basis: The presence of laryngeal carcinoma requires precise assessment of the feasibility of endotracheal intubation. Preliminary examination of the laryngeal structures is helpful in the selection of proper technique for ventilation. The Aim of the study is to determine the degree of laryngeal obstruction and anesthetic management in patients with laryngeal carcinoma. Materials and Methods: A prospective cohort study for determining the degree of laryngeal obstruction including 120 patients with laryngeal carcinoma operated in the Department of Otorhinolaryngology at the University Hospital "Queen Giovanna" - ISUL, Sofia, 2012-2015. Results: Preoperative examination of the larynx is performed in all patients by Storz 8402 ZX fiber optic laryngoscope with video capability. The degree of laryngeal obstruction is determined by the Cotton-Myer scale. In 60 patients the degree of obstruction is up to 50% (1st degree), in 26 patients it is 51-70% (2nd degree), and in 34 patients the obstruction is 71-99% (3rd degree). The instrumentation of upper airways depends on the degree of obstruction. Conclusion: Preoperative


determination of the degree of laryngeal obstruction is essential for choosing the proper technique for ventilation during tracheostomy in patients with laryngeal carcinoma. Key wards: Carcinoma of the larynx, laryngeal obstruction, fibrolaryngoscopy LARYNGEAL CARCINOMA – AN ANESTHETIC CHALLENGE Marinov Ts.1, M. Belitova1, T. Popov2, D. Konov2, M. Tsekova-Chernopolska2 1Department

of Anesthesiology and Intensive Care; University Hospital “Queen Giovanna”ISUL; Medical University-Sofia 2Department

of ENT Surgery; University Hospital “Queen Giovanna”- ISUL; Medical University-Sofia Introduction: Laryngeal carcinoma is the eleventh of the most common malignant neoplasms found in men. Epidemiologically it represents 1.6-2% of all malignant tumors in males and 0.2-0.4% in females. The Aim of the study is to characterize the significance of laryngeal carcinoma in the population. Materials and methods: Retrospective analysis of patient records. Analysis of the following parameters has been made: age, sex, risk factors, type and frequency of accompanying diseases, ASA. Patients are divided into two groups according to the type of the surgical intervention: 1. Patients undergoing fronto-lateral resection, 2. Patients undergoing total laryngectomy. Results: In both groups most the age of most patients is 51 to 60 years, the male sex is dominant, most of the patients are assessed with ASA III. Systemic alcohol use was reported by 195 patients who underwent fronto-lateral resection and by 520 patients who underwent total laryngectomy. Smoking was reported by 335 patients who underwent fronto-lateral resection and 840 of those who underwent total laryngectomy. Discussion: The predominance of patients in working-age (51-60 years) determines the social significance of the problem. A high percentage of risk factors were found in the study. Conclusion: Laryngeal carcinoma is malignancy with high occurrence and social significance, affecting mostly males in active working-age. Key wards: Carcinoma of the larynx, risk factors, significance

THE IMPORTANCE OF THE EXTRACORPOREAL SEPTOPLASTY IN RHINOPLASTY Dzhambazov K. Medical university- Plovdiv, ENT department University hospital “St. George”- Plovdiv


Septal deviations present a problem both aesthetically and functionally. Correcting severe septal deviations during the rhinoplasty procedure presents the surgeon with a great challenge. The conventional septoplasty approach is still the standard in treating many deviated septa but may not be suitable for severe cases which will require a more aggressive approach. The extracorporeal septoplasty is a relatively new yet rapidly evolving and highly effective method in rhinoseptoplasty for correcting septal deformities and thus restoring the nasal functions. In our three-year study (from 2015 to 2017), we performed extracorporeal septoplasty to 31 patients who underwent rhinoplasty. The patients were all evaluated and photographed preoperatively and postoperatively (after 6 and 12 months). The collected data shows minimal complications like bleeding, septal perforations or aesthetic deformities. The results also indicate that the extracorporeal technique improves both the nasal airway and the patient’s appearance. Key words: extracorporeal septoplasty, rhinoplasty, septal deviations

DIAGNOSTIC ROLE OF ACOUSTIC PHARYNGOMETRY IN OBSTRUCTIVE SLEEP APNEA SCREENING G. Shivarov, R. Radev, O. Terzi, L. Kanhush, I. Mirchev, Zh. Tancheva, V. Minkov, B. Naydenov, K. Todorova Division of Otorhinolaryngology, St. Anna Hospital of Varna, Varna, Bulgaria According to a variety of epidemiological studies, symptomatic moderate-to-severe obstructive sleep apnea affects between 6% and 25% of the population. The current goldstandard method of diagnosing this common disorder is in-laboratory polysomnography that is, however, cumbersome and expensive. Recently, acoustic pharyngometry is becoming widely used to triage efficiently patients at risk of obstructive sleep apnea. This method uses sound reflection to assess quickly (within five min. only) the cross-sectional area of the upper airway as a function of distance from the oral opening and to predict the presence of snoring with or without obstructive sleep apnea in adults and children. Our purpose was to evaluate the diagnostic capacity of acoustic pharyngometry as an intergral component of the rhinolaryngological screening examinations of snoring and obstructive sleep apnea. In 2016 and 2017, the staff of the Division of Otorhinolaryngology at St. Marina Hospital of Varna implemented a Municipal Programme entitled ‘Sleep Apnea Prevention’. The screening procedures covered a total of 702 subjects. Males were aged between nine and 91 years and females were aged between 27 and 92 years. Most individuals were between 41 and 60 years old. All of them were examined by means of acoustic pharyngometry, acoustic


rhinometry, anterior rhinoscopy, indirect pharyngoscopy and laryngoscopy, physical examination, and Epworth Sleepiness Scale. A risk of obstructive sleep apnea was identified in almost two thirds of the subjects. Soft palate ptosis, elongated uvula, deviated nasal septum and chronic rhinitis were most commonly diagnosed as anatomical reasons for snoring and obstructive sleep apnea. There was upper respiratory tracts obstruction at two levels and, less frequently, at nasal and pharyngeal level as well. Surgical treatment by radiofrequency thermotherapy was properly recommended for the majority of relatively severe cases. Our results convincingly prove that acoustic pharyngometry can be applied to precisely calculate the measures of oral and pharyngeal lengths and volumes as well as to detect the pathological alterations causing these sleep breathing disorders. This method is relatively inexpensive, easy-to-administer and non-invasive. Its strong independent predictive value makes it suitable for screening purposes.

OUR EXPERIENCE WITH THE APPLICATION OF ACOUSTIC PHARYNGOMETRY IN SNORING AND OBSTRUCTIVE SLEEP APNEA G. Shivarov Division of Otorhinolaryngology, St. Anna Hospital of Varna, Varna, Bulgaria Incidence rates of snoring and obstructive sleep apnea in childhood and adulthood continuously rise worldwide and in Bulgaria as well. Nowadays a wide range of screening and diagnostic methods of this common pathology are used. Here belongs acoustic pharyngometry, too. The objective of the present communication was to share our initial experience gained for the first time in Bulgaria with acoustic pharyngometry within a complex rhinolaryngological examination of the patients with snoring and obstructive sleep apnea. During the period from July 1, 2016 to December 31, 2016, a total of 276 patients commonly complaining of these sleep breathing disorders were examined in the Division of Otorhinolaryngology at St. Anna Hospital of Varna, Bulgaria. Along with acoustic pharyngometry performed by means of an apparatus of Eccovision firm (Boston, MA, USA), the following diagnostic methods were applied: anterior rhinoscopy, pharyngoscopy, indirect laryngoscopy, and acoustic rhinometry. This study covered 62 patients at a mean age of 56,17±10,92 years, 33 males at a mean age of 60,23±9,84 years, and 29 females at a mean age of 54,45±11,22 years.


We diagnosed the following pathology: deviated nasal septum, chronic hypertrophic rhinitis and soft palate ptosis (in 13 males and six females), deviated nasal septum, chronic hypertrophic rhinitis and elongated uvula (in seven males and three females), chronic hypertrophic rhinitis only (in four males and one female), etc. Soft palate ptosis and elongated uvula were detected by acoustic pharyngometry only in 44 and 19 patients, respectively. The values of the pharyngometric parameters of the oropharyngeal space such as airflow volume in the oropharynx, mean and minimal cross-section areas of the upper respiratory tract as well as distance between incisors and soft palate varied within broad limits depending on the specific oropharyngeal diseases as probable causes for snoring and obstructive sleep apnea. Our results allow us to draw the conclusion that the method of acoustic pharyngometry should occupy a well-deserved place in the complex diagnostic work-up of these sleep breathing disorders in our country, too.

ENDOSCOPIC SINUS SURGERY – FOUR HANDS TECHNIQUE Zlatanov Hr., Milev S. – Department of Otorhinolaryngology – Military Medical Academy-Sofia Minkin Kr.- Department of Neurosurgery- UMBAL “St. Iv. Rilski” Sofia Objectives: to present the technique of endoscopic sinus surgery performed by a team of two surgeons for the management of skull base tumors. Materials and methods: retrospective analysis of 8 cases of patients who had tumors of the nose, sinuses and skull base and were treated in the clinics with four hands endoscopic surgical techniques in the span of one year. Comparing the pre- and postoperative status of the patients. Results: in the span of one year we used the technique to treat two cases of CSF leak, three cases of pituitary adenoma and three cases of SCC of the paranasal sinuses. Conclusions: the four hands technique for endoscopic sinus surgery allows for extended and complex sinus and skull base resections, as well as work in a team with neurosurgeons in cases of pituitary adenomas.

VEMP - HISTORY AND METHOD DEVELOPMENT OVER THE YEARS Kalina Madzharova, Ana Behkova Faculty of Medicine; Medical University – Plovdiv


Otorhinolaryngology Clinic, University Hospital "Sv. Georgi" EAD – Plovdiv The authors track the onset and development of vestibular-evoked myogenic potentials for the study of vestibular diseases. For the first time, Bekesy in 1935 recorded myogenic potentials in acoustic irritation. Later Bikford, Tausend, Colebath, Halmagyi and others worked on registering myogenic potentials. The beginning of the study with cVEMP, the cervical vestibulo-evolved myogenic potentials, was launched in 1994 and with oVEMP - ocular vestibulo-evolved myogenic potentials in 2009. Given the difficulty of objectivizing vestibular symptomatology, scientists continuously improve the methodology. New opportunities for diagnosis and traceability are discovered in Otoneurology and Neurology. VEMP is a relatively new method for which there is no sanitization, but in recent years has been applied in Otorhinolaryngology practice.

ASSESSMENT OF AUDITORY REHABILITATION IN CHILDREN UP TO 2 YEARS OLD AFTER THE USAGE OF HEARING AIDS Katarzyna Cywka1*, Anna Sztabnicka1*, Piotr Henryk Skarżyński1*,2*,3* The thesis presents audiometric results and assessment of the development of auditory perception based on the LittlEars questionnaire after the using of hearing aids in children to 2 years of age. Appropriate selection and setting of hearing aids and the start hearing rehabilitation will determine the proper development of the child's hearing. Because audiometric tests only allow to assess the level of sound detection it is necessary to use questionnaires that allow reliable assessment of the benefits of the equipment used. The using of questionnaires allows to monitoring progress in terms of hearing development with children which used hearing aids. The aim of study is evaluation of progress of auditory rehabilitation in children up to 2 years of age after the use of hearing aids and comparison of hearing perception with children which are hearing correctly. The research group consisted of 38 children to 2 years old; 18 children using hearing aids on bone conduction and 20 children with hearing aids on air conduction. In order to assess the progress of rehabilitation and development of auditory perception after using of hearing aids we conducted a researches audiometric tests and polish version LittlEars questionnaire.


The results of audiometric BOA test showed improvement auditory reactions. The analysis of the results LittlEars questionnaire indicates progress in the auditory ability of children which used hearing aids. The using of hearing aids in children with hearing loss gives possibility to proper development of hearing perception. The using of questionnaire supports audiological assessment and allows the monitoring of hearing development. Comparing development auditory reactions before and after using of hearing aids, there are considerable progress in the development of auditory skills. Currently the number questionnaires in polish language is very small, therefore create a tools adapted accordingly, and intended for children younger than 2 years old.

ASSESSMENT OF EFFECTIVENESS OF THE HEARING AIDS FOR PATIENTS WITH SUDDEN DEAFNESS Anna Sztabnicka1*, Katarzyna Cywka1*, Piotr Henryk Skarżyński1*2*3* Sudden deafness is a receiving hearing impaired which appearing suddenly, without cause, in most cases one-sidedly with different levels of hearing loss including total deafness. The medical definition of sudden deafness is receiving (sensory-nerve) worsening of hearing by at least 30 dB at least three adjacent frequencies which grows no longer than 3 days. The prognosis for the return of hearing is very different and depend on factors coexisting. The aim of study is to evaluate the effectiveness of the use of hearing aids in patients with sudden deafness in which using pharmacological and therapeutic procedure has not produced the expected results. The research group consisted of 20 patients after an incident of sudden hearing loss which and they are use hearing aids for air conduction. In order to evaluate the effectiveness of prostheses utilized performed with patients we used audiometric verbal test in the free field and conducted questionnaire surveys designed to identify patients’ subjective opinions on the use of hearing aids in everyday situations. The analysis of completed questionnaires and conducted audiometric tests indicate no significant improvement in the quality and comfort of hearing after the application of hearing aids for air conduction. Patients with sudden hearing loss often do not achieve the anticipated benefits of hearing aids in use. In the case of this group of patients the time in which the diagnosis was made is very important and which are therapeutic procedures were applied.


With the extending of the eligibility criteria for implantation of cochlear implants, patients with sudden deafness who do not benefit from hearing aids may be implants users.

NASAL SEPTAL LOBULAR CAPILLARY HAEMANGIOMA: A CASE REPORT Konstantinos Valsamidis1*, Astreinidou Anna1*, Iliana Efstathiou1*, Eleonora Avramopoulou1*, Vasiliki Florou1*, Nektarios Argyriou1*, Nikolaos Kamargiannis1* Lobular capillary hemangioma is a benign vascular neoplasm which commonly affects the skin, mucosa of the oral cavity and tongue [1]. Nasal cavity mucosa involvement is very rare and if it occurs, the commonest affected site is the nasal septum [2]. Although the actual cause is unknown, factors such as previous nasal trauma from nasal packing and prolonged intubation, and hormonal factors which include pregnancy had been implicated in the etiology of the lesion [2, 3]. The most frequent symptoms of lobular capillary hemangioma include unilateral epistaxis and nasal obstruction [2, 4]. Our principal aim was to highlight the importance of considering this lesion as a differential diagnosis for unilateral nasal obstruction and epistaxis. A 38-year-old female patient, presented in the ENT department with a 6-month history of progressive left nasal blockage associated with blood-stained left-sided nasal discharge. She mentioned a natural childbirth 15 days ago and had no pre-morbid history of nasal intubation, instrumentation or packing. During nasal endoscopy, there was an obstructive left intranasal reddish brown, ulcerated polypoid mass which was attached to the anterior aspect of the nasal septum by a pedicle. The mass was sensitive to touch and bled easily on contact. CT sinus scan revealed a roundish area of lucency with sclerotic (opaque) rim in the left nasal cavity. The paranasal sinuses appeared clear and normal. The lesion was removed by a per-nasal excision biopsy under local anesthesia. Histology report was conclusive of a Lobular Capillary Hemangioma. The patient has been followed up for two years with complete healing of the site without any recurrence. Lobular capillary hemangioma should be considered in the differential diagnosis of all endonasal masses associated with unilateral epistaxis and nasal obstruction. Endoscopic total excision with bipolar electrocautery for hemostasis is an appropriate treatment.

EFFECTS OF SEPTOPLASTY ON NASAL PATENCY AND OLFACTION OF PATIENTS WITH NASAL OBSTRUCTION DUE TO NASAL SEPTUM DEVIATION Valsamidis Konstantinos1*, Titelis Konstantinos1*, Rachovitsas Dimitrios2*, Triaridis Stefanos2*


The aim of this study was to investigate the effects of septoplasty on nasal patency and olfaction of patients with symptoms of nasal obstruction due to nasal septum deviation. Methods: In this prospective observational study, a total of 60 patients (34 men and 26 women), aged between 18 and 63 years (mean age 32.98 ± 11.98) and 25 healthy controls (13 men and 12 women), aged between 21 and 58 years (mean age 29 ± 8.87) were included. Anterior Rhinomanometry (RM) and Acoustic rhinometry (AR) were utilized for the assessment of nasal resistance and nasal patency respectively, preoperatively and at six months after septoplasty [1, 2]. Olfactory function was assessed using the Sniffin’ Sticks test package with 12 with specific tests for odor threshold (OT), odor discrimination (OD), and odor identification (OI). Results were aggregated to odor threshold, odor discrimination, and odor identification (TDI) score [3]. Results: Preoperatively, statistically significant differences were observed in all the nasal objective measurements (Total Nasal Resistance – TNR, Minimal Cross-Sectional Area MCSA and Total nasal cavity volume – Tvol) and olfactory scores between patient and control group. Postoperative evaluations showed statistically significant improvement for RM and AR parameters as well as for OT and TDI scores. At 6-month follow up there were no statistically significant differences for RM and AR measurements between patients and healthy controls. However, olfactory scores (except for OT) in patients’ group remained statistically significantly lower compared to the control group. Additionally, no statistically significant correlations were found between objective nasal measurements (RM and AR values) and olfactory scores.

SALIVARY DUCT CARCINOMA OF THE SUBMANDIBULAR GLAND: AN EXTREMELY RARE AND AGGRESSIVE MALIGNANCY Konstantinos Valsamidis1*, Iliana Efstathiou1*, Anna Astreinidou1*, Nektarios Argyriou1*, Vasiliki Florou1*, Nikolaos Kamargiannis1* The incidence of Salivary Duct Carcinoma (SDC) is reported to be 1-3% of all salivary gland carcinomas [1]. In the vast majority of cases, the tumor affects the parotid gland (88% of the cases). The submandibular gland and the small salivary glands are also less frequently affected (8% and 4% of the cases respectively) [2]. This report presents a case of a patient with a SDC of the submandibular gland. Taking into account the literature, the clinical and histological features, as well as treatment options of this tumor are presented. A 70-year-old woman was referred in our Department complaining of intermittent swelling on the neck area, formed over 4 months. On physical examination, a hard and painful mass over the left submandibular area was noted. Computed tomography (CT) showed a


homogenous enhanced 2 × 1.5 1.5.cm tumor of the left submandibular gland. There were no pathological cervical lymph nodes. Excision of the submandibular gland was performed. During this operation, the tumor was found adhesive to the surrounding tissue. Salivary duct carcinoma was diagnosed by histopathologic examination and immunochemistry. Post-operative radiotherapy was carried out. There has been no tumor recurrence or distant metastasis for 12 months after surgery. Salivary Duct Carcinoma (SDC) of the submandibular gland is a rare, very aggressive malignancy with a high rate of recurrence and metastasis despite surgery and adjuvant radiation. Survival is poor, with most patients surviving only about three years after diagnosis [3]. Immunotherapy combined with targeted therapy may be a promising avenue for this disease. Therefore, systemic treatment with trastuzumab, androgen deprivation, and other targeted therapies deserve further study, and biomarkers are needed to predict which patients might respond [4, 5].

AN UNUSUAL WARTHIN’S TUMOR ARISING FROM A CERVICAL LYMPH NODE IN FRONT OF THE CAROTID ARTERY Konstantinos Valsamidis1*, Iliana Efstathiou1*, Eleonora Avramopoulou1*, Nektarios Argyriou1*, Vasiliki Florou1*, Nikolaos Kamargiannis1* Warthin tumor, also known as cystadenolymphoma, accounts for 4% to 13% of all salivary gland tumors [1]. This benign tumor, which commonly arises in the parotid gland, shows a predilection for males, with a peak of incidence during the sixth decade of life. Extraparotid Warthin’s tumor may be arising from the submandibular gland, minor salivary glands and cervical lymph nodes but is very infrequent and extremely rare [2]. In this report an unusual case of a Warthin tumor arising from a cervical lymph node in front of the bifurcation of the carotid artery, is presented. A 56-year-old woman was referred to the ENT department because she noticed swelling on the right neck area 8 months ago, with gradual and slow growing but with no other symptoms. The patient was a smoker. During clinical examination, the mass appeared palpable, circumscribed and painless. Computed tomography (CT) scan revealed a soft tissue tumor with cystic elements and heterogeneous enhancement next to the bifurcation of the carotid artery, sizing 3 cm×2.2 cm×2 cm. The tumor was surgically excised under general anesthesia. Macroscopically, the lesion presented as an ovoid mass, with a dense fibrous capsule and cystic compartments filled with a viscous yellow material. Histopathologic examination revealed double-layered oncocytic epithelium lining the cystic space associated with a prominent lymphoid component in the stroma, characteristic


features of Warthin tumor. There was no evidence of malignancy. The postoperative course was uneventful, with no recurrence at 10-month follow-up. Warthin tumor is a unique entity of benign salivary gland tumors because of its histopathological appearance and unknown origin. The etiology of Warthin tumor remains unknown but appears to be strongly related to smoking [3]. The treatment of choice is complete local excision with a wide tumor free margins and a long period follow up to prevent or early detect the possibility of recurrence [2].

AN UNUSUAL CASE OF OSLER â&#x20AC;&#x201C; WEBER - RENDU SYNDROME Iliana Efstathiou1*, Konstantinos Valsamidis1*, Nektarios Argyriou1*, Dimitrios Paikos 2* Nikolaos Kamargiannis1* Osler Weber Rendu or Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant disorder with vascular dysplasia [1]. It is characterized by epistaxis, telangiectasia, visceral arteriovenous malformations and positive family history [2]. Complications can occur from the gastrointestinal, pulmonary, nervous system because of the arteriovenous malformations in several organs. This report presents a case of a patient with HHT. A 38-year-old woman referred in the gastroenterology department to be evaluated as a possible primary biliary cirrhosis. During the physical examination telangiectasia lesions were noticed in multiple locations at her lips and tongue. The patient reported recurrent epistaxis and the family history revealed presence of individuals in every generation of the family with epistaxis and telangiectatic lesions. ENT evaluation was requested. From the clinical examination, rhinoscopy telangiectatic lesions were found on her septal mucosa, lips and tongue. The endoscopic examination of gastrointestinal system revealed several visceral lesions in the second part of the stomach till the jejunum, with some of them being hemorrhagic, while MRI and MRCP revealed cholangitis due to HHT. Hereditary Hemorrhagic Telangiectasia (HHT) is most commonly first presented with repetition epistaxis [3] and telangiectasias in characteristic sites which include the lips, the oral cavity and the nose [1]. Thus, it is important for the otorinolaringologists to be aware of the syndrome and its characteristic manifestations in order to perform correct diagnosis and guidance to prevent the complications [4].

LARYNGEAL TUBERCULOSIS MASQUERADING AS CARCINOMA Mahmut S. Yilmaz1, Mehmet Guven1, Ahmet Kara1, Deniz Demir1


Laryngeal tuberculosis is the most common granulomatous inflammatory disease of the larynx. It usually occurs as a complication of pulmonary tuberculosis. In most of the cases hoarseness is the major symptom and systemic symptoms is relatively rare. It mimics carcinoma of the larynx. Pulmonary X-ray and positive sputum cultures contribute to the diagnosis but definitive diagnosis of the laryngeal tuberculosis is based on histopathologic findings of the biopsy specimen. In this report we present a case with laryngeal tuberculosis and aim to discuss the differential diagnosis and treatment of laryngeal tuberculosis. Although it occurs rarely laryngeal tuberculosis should be considered in the differential diagnosis of laryngeal masses.

TREATMENT OF THE FACIAL NERVE PALSY AS A COMPLICATION OF THE OTITIS CHRONICA MEDIA-CASE REPORT Jankulovska M.1*, Davcheva-Chakar M. 2*, Todevska Cvjetik T. 3*, Marolov M. 4* The facial nerve palsy as a clinical entitle in otorhynolaryngology is a common case in everyday practice. From one side, it is a very stressful situation for the patient, because of the affection of the muscles innerved by this nerve, as well for the physical appearance change and influence in the person's everyday lifestyle. From the other side it is a big challenge for the doctor to make the diagnosis, especially find the cause (idiopathic, infection, tumors, complication of infection) and properly treat, so he/she can improve the quality of life of the patients. To present the principles of the diagnosis and treatment of the facial nerve palsy as a complication of the chronic otitis media in the ENT clinic Skopje. Case report of the patient with peripheral facial nerve palsy as a complication of chronic otitis media, from the moment of the diagnosis, conservative and surgical treatment and follow up in the next two months. S.N., sixty year old female was sent to ENT clinic of Skopje. She was previously treated conservatively in the clinical hospital of Tetovo for chronic otitis media of the left ear for four days. The situation got worst and the fourth day, facial nerve palsy signs appeared. In our hospital she was first examined in the polyclinics, the otomicroscopy examination was done and purulent pulsative secretion in the external auditory canal was visualized. Next step was sending to the audiology department where pure tone audiometry was done. Results: Mild sensorineural hearing loss on the right ear and moderate mixed hearing loss on the left ear. The patient was hospitalized and further examination continued. CT scan results were according to the clinical symptoms of the chronic otitis media and mastoiditis. There werenâ&#x20AC;&#x2122;t definitive signs of the facial nerve canal dehiscence on the images. The


antibiotics and corticosteroid therapy were administrated. The next day the clinical symptoms got worst, patient got vertigo. The decision for the surgical treatment was made then. In general anesthesia mastoidectomy was done, a lot of granulation tissue was found, especially in the apex. In the tympani cavity the destruction of the ossicles was found and dehiscence of the tympanal part of the facial nerve. The canal wall down mastoidectomy was finished, and then the decompression of the facial nerve started from the tympanal part, the second genu and mastoid part respectively. The perineurium of the nerve was released. After the operation the patient was followed up in the department. After the second day, the symptoms of the facial nerve palsy improved and every next day got better. All the time the complete blood count was controlled. The 10th day she was sent home with visible improvement of the symptoms. The early diagnosis and the complementary conservative and surgical approach are essential in the facial nerve palsy treatment as a complication of the chronic media otitis.

ADVANCED MALIGN OTİTİS EXTERNA, REPORT OF 4 CASES Ahmet Kara1*, Mehmet Güven2*, Muhammed Ali Özçelik3*, Mahmut Sinan Yılmaz4*, Fatih Turan5*, Bilgehan Çelik6* The diagnosis and treatment of the patients with malignant otitis externa is a big challenge for surgeons. Recurrence of the disease, cranial nerve paralysis, spreading of the infection to the labyrinth and intracranial spaces, and life-threatening complications are always possible in the normal process of the disease. In this report we represented 4 patients and 5 sides with advanced malign otitis externa. The main complaint for the clinical application was severe otalgia. One of the patients was treated with hyperbarique oxygen therapy and systemic antibiotherapy. However all of the others were needed surgical procedures in addition to medical treatments. We performed subtotal petrosectomies for three ears and a total petrosectomy for one side. The patient who were operated with total and subtotal petrosectomies respectively were also implanted with a cochlear implant after a healing period with dummy electrode then subtotal petrosectomy procedure. Three of the patients are still in clinic follow-up. However one of them have died due to neurologic disorders. Systemic antibiotherapy, hyperbarique oxygen therapy and blood glucose regulation are indispensable parts of the treatment methods for malign otitis externa. However extensive surgical procedures may also necessary, too. The patients with intact cochlea may also be treated with cochlear stimulation.


ARE NEUTROPHIL, PLATELET,AND EOSINOPHIL-TO-LYMPHOCYTE RATIO AND MEAN PLATELET VOLUME REALLY POTENTIAL PREDICTOR FOR OTITIS MEDIA WITH CHRONIC EFFUSION Oguz Kadir Egilmez1*, Mehmet Guven1*, Mahmut Sinan Yilmaz1*, Deniz Demir1*, Bilgehan Celik1* Otitis media with effusion is an inflammatory disease characterized by fluid accumulation in the middle ear. The aim of this study is to investigate the predictive role of neutrophil, platelet, and eosinophil-to-lymphocyte ratio and mean platelet volume in adult patients having otitis media with effusion and to compare with control subjects; analyze whether they could be a potential predictor parameter to predict the disease progression. In our study, we retrospectively analyzed 69 patients (44 male, 25 female) between the ages of 18-50 having only chronic otitis media with effusion, and 69 age- and sex matched (between ages of 18-50; 38 male, 31 female) healthy controls. Study and control groups were compared with each other for MPV, neutrophil-to-lymphocyte, platelet-to-lymphocyte, and eosinophil-to-lymphocyte ratios. When the otitis media with effusion patient group and the control group were compared, no statistically significant difference was found between two groups for NLR, PLR, ELR and MPV (p=0.646, 0.843, 0.16, 0.769, respectively). In the literature; although it is anticipated in some previous studies that these values may be used in predicting diseases, it is obvious that more detailed studies are needed in order to make this clear. When considering such values, it is necessary to pay attention and not to consider only these results about disease prediction.

ESOPHAGEAL PERFORATION DUE TO DIFFICULT INTUBATION: CASE REPORT Ömer Erdur1*, Osman Gül1*, Yunus E. Topan1, Kayhan Öztürk1 If the endotracheal intubation is performed electively, perforation of the trachea and/or esophagus is a rare occurrence. However, when the procedure is done under emergency conditions and the patient has a difficult airway the possibility of traumatic damage to the airway is much greater, even when it is performed by a physician skilled in intubations. The aim of this study is to present a patient with esophageal perforation due to difficult intubation.


A 48-year-old female patient was found to have difficult airway when she underwent elective surgery. The patient's intubation failed. Emergency tracheotomy was performed due to the fall of the oxygen saturation of the patient and the patient was taken intensive care unit. Laceration at the esophagus entrance was detected on endoscopy of the patient. Endoscopy and computed tomography showed minimal lacerations at the esophagus entrance. The patient was followed for 15 days with conservative treatment. A surgical operation was planned because there is no improvement in the general situation. In the operation, methylene blue was given by the nasogastric tube and the perforation area was seen. In the field of perforation, the esophagus mucosa was seen to be turned out. The mucosa was placed and the esophagus was sutured as 3 layers. The operation was terminated without complications. The patient was fed nasogastric tube following 2 weeks. After 2 weeks, esophageal leakage was not observed. Management of most esophageal perforations consist of surgical repair of the lesion but small cervical esophagus lesions with minimal symptoms and with no evidence of serious complications can be treated conservatively. Although there is a small laceration in our patient, conservative treatment failed. We think that entering the esophageal mucosa into laceration edges negatively affects recovery.

SUBGLOTTIC STENOSIS DUE TO EMERGENCY TRACHEOSTOMY: CASE REPORT Osman Gül1*, Ömer Erdur1*, Yunus E. Topan1, Kayhan Öztürk1 The traumatic damage due to the decubitus of the endotracheal tube or tracheotomy cannula or caused by the pressure exerted by their cuffs is the most common causes of iatrogenic tracheal stenosis. The ischemic and necrotic damage and possible cartilaginous involvement (fractures) lead to a redundant reparation process with consequent cicatricle tracheal stenosis. The aim of this study is to present a patient had subglottic stenosis due to emergency tracheostomy and its management. A 45-year-old woman developed bilateral vocal cord paralysis after thyroidectomy. 9 months after surgery, severe respiratory distress developed and emergency tracheostomy was performed. The patient was consulted to our clinic for persistent dyspnea. Tracheostomy area was seen to be above settlement. On laryngoscopic examination, there were bilaterally vocal cords paralysis and granulation tissue was observed in the subglottic region. The patient's tracheostomy site was revised. In the operation it was seen that the previous tracheostomy was made at the cricoid cartilage area and there was a fracture in the cricoid cartilage. The patient underwent stenosis surgery 7 times in the last one year. At


4 operations, granulation tissue was excised with laser and stent was placed. In 3 operations, vocal cortectomy and or cordotomy were performed. Despite all the initiatives, adequate improvement was not achieved in the patient. Stenosis after up localized tracheotomy is a severe condition and difficult to treat. Even in an emergency condition, care should be taken to administer the tracheostomy under the cricoid cartilage and not to damage the cricoid cartilage. Even if the tracheostomy is made at or above the cricoid cartilage line, it should be replaced to correct position as soon as possible.

COCHLEAR IMPLANTATION IN PATIENT WITH BILATERAL TEMPORAL FRACTURES: CASE REPORT Bahar Çolpan1*, Osman Gül1*, Ömer Erdur1 Temporal bone fractures can cause loss of audiovestibular function. We present the case of a 20-year-old man who had bilateral total hearing loss after bilateral temporal bone fractures due to head trauma. The patient who applied to the hospital after the traffic accident was followed up for 10 days due to subarachnoid hemorrhage and subdural hematoma in brain surgery intensive care unit. In the temporal tomography of the patient who described hearing loss after externed intensive care unit, fractures passing through the bilateral semicircular canals were observed. Vestibulocochlear nerve was intact in temporal MRI. Bilateral total hearing loss was observed in the audiogram and ABR tests performed to the patient. No vestibular symptoms were observed in the patient. The patient received systemic steroid therapy for 10 days. Bilateral cochlear implant surgery was performed in the patient who had no improvement in their tests 1 month after the accident. There were no complications in the surgery. The patient demonstrated much improved audiometric and psychoacoustic performance after bilateral cochlear implantation. Temporal bone fracture, which involves the otic capsule, can lead to complete loss of auditory and vestibular functions, whereas the patients without fractures may experience profound sensorineural hearing loss due to cochlear concussion. Temporal bone fracture may result in destruction and degeneration of hair cells, supporting cells, and ganglion. Cochlear implantation is an effective aural rehabilitation in profound sensorineural hearing loss caused by temporal bone trauma.


BILATERAL COCHLEAR IMPLANT IN PATIENT WITH VENTRICULOPERITONEAL SHUNT CASE REPORT Bahar Çolpan1*, Osman Gül1*, Ömer Erdur1, Bülent Ulusoy1 Cochlear implants and ventriculoperitoneal shunts (VPS) are common devices used to treat hearing loss and hydrocephalus. However, it is rare for a patient to require both treatments. When this occurs, the potential for complications may increase when considering the surgical anatomy, technology, and the interaction of the underlying comorbidities of the patient. We describe the CI case of a 3-year-old child with an implanted VPS device, and its clinical, audiological, and radiological features, surgical techniques, and postoperative functional outcomes. Case Report A 3 years old child with congenital bilateral hearing loss was included in the study. The child had congenital hydrocephalus and implanted VPS. After 1 year of follow-up with the hearing aids, bilateral cochlear implant application was planned. There were no cochlear and retrocochlear pathologies in BT and MRI. Surgery was performed after the patient was prepared for the cochlear implant. During the CI, care was taken to place the CI device at a sufficient distance from the shunt. So that the shunt would not be affected by the magnetic field. We were very careful not to pull the shunt catheter out of position while the musculoperiosteal flap was elevated. No complications were observed during and after surgery. The patient demonstrated much improved audiometric and psychoacoustic performance after bilateral cochlear implantation. Cochlear implant is an effective surgery in rehabilitation of hearing loss in patients with hydrocephalus and VPS. The following should be observed during surgery: the implant is placed far enough from the shunt and the shunt is not damaged during the operation. Patients with hydrocephalus and severe-to-profound hearing loss are a unique patient population with unique pre-, intra-, and post-operative issues. Thorough understanding of the indications, radiology, anatomy, technology, and potential complications can allow for these patients to achieve the full benefit of these life-changing surgeries.

VESTIBULAR SCHWANNOMA – COMPLEX DIAGNOSTIC SPECIALISED OUTPATIENT MEDICAL PRACTICE Polya Bozhinova, Stoyan Bozhinov ⃰, Mario Milkov

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Galileo Medical Centre, Medical University Pleven â&#x192;° Introduction: The vestibular schwannoma or acoustic neurinoma is a benign tumor that is derived from the Schwann cells that form the myelin sheath of the superior vestibular nerve (part of the vestibulocochlear nerve), but it can also come from the inferior vestibular nerve and rarely from the auditory nerve. Vestibular schwannoma constitutes around 80-85% of the tumors of the cerebellopontine angle and 10% of all intracranial tumors. It is wellcapsulated and compresses the nerve without invading it. Vestibular schwannoma grows up slowly (around 2 mm per year). Some tumors grow up faster while others shrink and disappear. The tumor frequency varies and is limited to 1 in 100 000 (new cases per year) and 70 in 100 000 in the overall population. Findings show that it equally affects men and women. The typical schwannoma begins its growth in the period between 40 and 60 years and the frequency increases with age. The earliest symptoms of vestibular schwannoma are unilateral hearing loss and tinnitus, accompanied by a significant impairment of speech comprehension. In the beginning there are no vestibular symptoms which can be explained with the slow growth of the tumor giving time to the healthy vestibular organ and the other balance systems to compensate for the damaged vestibular apparatus. This means that the early signs of patients with vestibular schwannoma are merely audiological and the vestibular symptoms (impaired balance, dizziness and systematic vertigo) appear at a later stage. The growth of the tumor can also affect adjacent anatomical structures and cause other symptoms such as headache, nausea, vomiting, facial paralysis, lack of corneal reflex and facial paresthesia. The therapeutic abilities include follow-up and monitoring of the small tumors (smaller than 20 mm), conventional surgery and radiosurgery. The therapeutic approach depends on the symptoms, the size of the tumor, and age and health condition of the patient. Aim: Finding early audiological and clinical signs of vestibular schwannoma Materials and methods: We made a retrospective analysis of clinical data from medical documents of our patients who have come to the ENT department of Galileo Medical Centre, Pleven with unilateral (83 patients) or asymmetric hearing loss (210 patients) for the last three years. We created and apply our own diagnostic protocol for evaluating patients with unilateral or asymmetric hearing loss which includes a questionnaire about the history and characteristics of the tinnitus and the hearing loss (complaints onset and their relation to auditory trauma, severe viral infection, vascular incident, ototoxic agents or cerebro-cranial trauma) and a number of audiological examinations and otoneurologic tests. In 57 patients who are suspected to have vestibular schwannoma according to our protocol we made additional neuroimaging tests. The remaining patients who have unilateral or asymmetric hearing loss but no direct signs of vestibular schwannoma are monitored clinically and audiologically once a year.


Results: Vestibular schwannoma was confirmed in three patients through CT scan of the brain with contrast. In one of the patients we performed additional MRI. Putting together the results from our own protocols allows for the identification of the significant signs for the presence of vestibular schwannoma. Although the most common early sign of neurinoma is tinnitus, a very small part of patients with unilateral tinnitus have a neurinoma. There are also many people with unilateral hearing loss who do not have a tumor. However, it is very important to always suspect this possibility when evaluating patients with unilateral hearing loss and tinnitus through the necessary examinations and clinical follow-up of the dynamics of the symptoms. The combination of an audiometry showing unilateral or asymmetric hearing loss, lack of acoustic reflex and ABR with prolonged latency of the pike of the fifth wave is distinctive for vestibular schwannoma. The results from the audiological, electrophysiological and neuroimaging tests should be compared and evaluated complexly. Conclusion: The presence of a vestibular schwannoma should be assumed in every patient with unilateral or asymmetric hearing loss and unilateral tinnitus when the patientâ&#x20AC;&#x2122;s symptoms cannot be explained with auditory trauma, severe viral infection or vascular incident (even transitory). Contrast neuroimaging of the cerebellopontine angle through CT and MRI has the highest level of evidence for the presence of a tumor process in comparison to the other methods.

LARGE GLOMUS JUGULARE TUMOR: CASE REPORT Erbay Demir, Selis G. GĂźven, Ahmet R. KarasalihoÄ&#x;lu Introduction: Glomus jugulare tumor is a rare and slow-growing tumor, originated from the paraganglia cells of adventia of juguler bulb. It commonly becomes symptomatic at the age of 50 years and it's almost six times more common in females than males. The first symptom is pulsatile tinnitus, followed by conductive type hearing loss. Neurological dysfunction of 9, 10, 11th cranial nerves may develop if tumor spreads to juguler foramen. As the tumor grows, it can destroy the bones and reach the middle ear, the posterior fossa, and the upper neck. Also it may cause destruction around the foramen magnum and compression on the brain stem. Despite the low prevalence, most of the patients have advanced disease because of late symptom onset, insidious growth and inaccessible location for examination (1). The most common radiological methods used in diagnosis are gadolinium magnetic resonance imaging (MRI), temporal computerized tomography scan (CT) and Digital Subtraction Angiograpy (DSA)(2). Surgery is difficult because they are very vascular tumors. Diagnostic


angiography and selective embolization are useful before surgery. Treatment options other than total surgical resection include stereotactic radiosurgery (SRS), such as gamma knife and cyber knife, or subtotal resection plus SRS (3). In this case report, we aimed to present a rare case of glomus jugulare tumor with intracranial extension (fisch classification type D2). Case report: A 69 year old female patient who had massive hemorrhage after paracentesis, consulted to our university hospital's ENT clinic and she admitted to the inpatient clinic with the diagnosis of paraganglioma. She has had tinnitus in the right ear for about 10 years and hearing loss in the right ear for several years. She also has had vertigo attacks with nausea and vomiting for one year. She hadn't any chronic illnesses except hypertension and had no disease related to ENT in the family history. Otoscopy shows that right tympanic membrane (TM) seen purple-red mass and pulsatile, also there is retraction at left TM (Figure 1). A vascular lesion compatible with 32x24 mm glomus jugulare at the level of the right foramen jugulare was detected in CT scan (Figure 2). MRI showed a mass corresponding to 4.8 x 2.2 cm paraganglioma at the right foramen jugular level (Figure 3). A tumor greater than 2 cm with intracranial growth was evaluated as D2 according to the classification of Fisch (4). The patient was consulted to the radiation oncology department and directed to a center where the SRS was available. Discussion: Here, we report 69 year old female patient with glomus jugulare tumor in the right ear. According to the literature, similar to our case, the tumor is more frequently seen in women at the fifth and sixth decades and mostly arise from the right ear. Unilateral conductive type hearing loss and pulsatile objective tinnitus are the most common symptoms of glomus jugulare tumor. Other symptoms are ear fullness, mild pain and hemorrhage. Involvement of the inner ear produces vertigo and sensorineural hearing loss. Occlusion of the foramen jugulare may cause paralysis of the 9, 10, 11th cranial nerves. As the tumor's intracranial spread increases, headache and papillary stasis may occur (5). Otoscopy shows a purple-red mass in the middle ear. The tympanogram may be evaluated as type B and it may mislead the physicians. Paracentesis and incisional biopsies are contraindicated in these tumors. Diagnosis is confirmed through radiological studies. The best imaging technique is high resonance temporal CT to investigate the widening of the jugular foramen and loss of bone lining. MRI studies with gadolinium contrast are recommended to investigate intracranial, neck and large vessels expansion. Another


diagnostic method which is commonly used is angiography. Pre-operative embolization can be performed with angiography at the same time. Ivan et al.conducted a meta-analysis in 2011 with 869 patients. According to the results, tumor control was higher in patients receiving SRS alone (95%) compared to total resection (86%) and subtotal resection (69%). The mean follow-up was also 1.5 years longer in the total resection group (88 months) compared to SRS (71 months) (3). The aim of the surgery is mainly complete resection of the lesion while the aim of the radiosurgery is commonly inhibition of tumor growth. Because of the fact that they have different aims, comparison between surgery and radiosurgery is difficult. According to the literature, the authors recommend that radiosurgery can be used as a primary therapy for patients who are elderly or have important comorbidities and as a secondary therapy in cases of subtotal resection, mainly in large tumors and residual tumors (6). We considered the previous data about the treatment options of glomus jugulare tumors in the literature and as a result directed the patient to a center where the SRS treatment was available because the patient was elderly and the tumor size was large. As a result, it is important to remember the glomus jugulare tumor before paracentesis. If physical examination and audiological tests are suspicious, it is useful to refer to radiological examinations.

LARYNGEAL ANGIOMYXOMA: CASE REPORT AND LITERATURE REVIEW Mehmet Güven1*, Sena Genç1*, Ahmet Kara1*, M.Sinan Yılmaz1* In this case report, a rare case of angiomyxoma will be described. A 45-year-old male patient admitted to our clinic with complaints of dysphonia, dyspnea and cough for 6 months. He had no history of a systemic disease, and was not smoker or alcohol user. On the laryngoscopic examination, a massive lesion with a smooth surface right band ventricle, right aryepiglottic fold, sinus piriformis filling, and rima glottic narrowing was seen. Laryngeal computed tomography scan showed soft tissue densities narrowing the airway space and originating from the right supraglottic area of the larynx.


In the patient who was diagnosed as laryngomucocele as an initial diagnosis, during microlaryngeal surgery soft tissue mass was encountered and the mass was exposed by blunt dissection. Since the mass could not be removed in the most block, it was excised in piecemeal form. The patient was followed once a week for the first month, and then once a month. There has been no recurrence for one year. Angiomyxoma is a rare, benign tumor of the larynx and should be considered in the differential diagnosis of larynx masses. The treatment of angiomyxomas of the larynx is surgical. The mass can be usually excised intraorally or endoscopically. Although angiomyxoma is a benign tumor, it can sometimes be aggressive. Because of the potential local recurrence or metastasis risk, we recommend postoperative periodic control examinations and long-term close follow-up postoperatively.

DEVELOPMENT OF A 3D MODEL OF THE MASTOID PROCESS AND THE COURSE OF THE FACIAL NERVE THROUGH IT Mirchev, Stefan University Hospital â&#x20AC;&#x201C; Pleven, Department of otorhinolaryngology The study of human body by medical students begins at the dissecting halls in anatomy classes and continues throughout the training and practice subsequently. Anatomical models for visualization and training for surgical interventions are also used during the process. There are anatomical zones which are hard to find and invisible. In order to be visualized and presented for their study, specific equipment (microscope, microtools, drill, etc.) and additional knowledge are required. The middle ear structures and the facial nerve in its intertemporal segment are also such. Objective: Creating a 3D model of mastoid processus in real size and the facial nerve part passing through it. Material and methods: 1. Cadaver Temporal Bone, on which Transmastoid Facial Nerve decompression has been performed; 2. Plastic material for taking the imprint; 3. Silicone model which has been elaborated in a laboratory. The facial nerve is represented in the section from Stylomastoid foramen to Geniculate ganglion. Its bone canal (canalis facial nerve) and the adjacent structures are visualized: the


three semicircular canals (semicircular canalis), the Oval window, and the Mastoid air cells, as well as the mastoid bone marrow cells (Mastoid process) are preserved to represent the type of pneumatization. The bone wall of the facial nerve is removed with a diamond bur and the latter is visualized. The facial nerve stem is pulled out with microtools and its canal is left empty. Imprints are taken in two stages with plastic material and the model is formed. In addition, the structures are coloured. Results: The model presents: 1. The boundaries of Mastoid processus and its closest structures: Middle cranial fossa, sigmoid sinus, apex mastoid tip, facial nerve -tympanic segment, and mastoid segment. 2. The facial nerve with the mastoid segment and the tympanic segment. Conclusions: Up to now, the middle ear models are informative, well-developed, but not real in size. The developed model recreates the real dimensions of the mastoid process and the structures, located in it and around it. The model facilitates the perception of the microstructures of the middle ear and the facial nerve, the location of the adjacent anatomical zones, and shows their relationship when a pathological process occurs. Approximate measurements can be made on the model, for example: facial nerve length, angle measurement between mastoid segment and tympanic segment, etc. The model can be used for training students, post-graduate students in neurology, neurosurgery and otorhinolaryngology. The model is suitable for obtaining basic knowledge about otosurgical training. The model can be used during talks to patients in order to obtain informed consent prior to upcoming interventions affecting the middle ear and endangering the facial nerve.

RARELY FOUND PAROTÄ°D MASS: MALT LYMPHOMA CASE REPORT Ă&#x2013;mer Erdur1*, Yunus Emre Topan1*,Osman GĂźl1


Primary lymphomas of salivary glands are quite rare. The majority of primary parotid gland lymphomas are low-grade B-cell lymphomas. Although non-Hodgkin's lymphomas are more common, follicular, marginal zone, and diffuse large B-cell lymphoma are more likely, and are associated with other histological definitions. However, mucosa-associated lymphoid tissue lymphoma is rarely seen in parotitis. The most common symptom is unilateral localized swelling without pain and facial paralysis. The basis of primary therapy is chemoradiotherapy after diagnosis. A 40-year-old woman without any illness was admitted to our clinic with localized painless swelling under her right ear for about 1 year. Superficial parotitectomy was performed to the patient who was diagnosed as benign mixed tumor after the examinations and fine needle biopsy. Specimens were reported as marginal zone-B lymphoma-mucosal-associated lenfoid tissue (MALT). Chemoradiotherapy was applied after oncology consultation postoperatively. There were no problems and no recurrence in 18 month follow-up of the patient after surgery. MALT lymphomas are classified as gastric and non-gastric by location. The most common sites of non-gastric MALT lymphomas are salivary glands, upper respiratory tract, thyroid liver, skin and stomach. Although etiopathogenesis is not fully understood, the most important factors are chronic inflammatory diseases and rheumatologic diseases. Parotid MALT lymphoma does not have standardized treatment strategy yet due to its rare occurrence. The primary lymphoma of the parotid gland is very difficult to distinguish from other benign masses of the parotid gland. Therefore, when examining parotid masses, MALT lymphoma and other lymphomas should be kept in mind at the differential diagnosis and multidisciplinary approach should be approached for treatment planning.

RECURRENT MENINGITIS WITH OVAL WINDOW DERIVED PERLYMPH FISTULA IN A 13 YEARS OLD CHILD: CASE REPORT Ömer Erdur1*, Yunus Emre Topan1*, Bahar Çolpan1, Turgut Çelik1 Osman Gül1 Authors institutions1: Selçuk University, Otorhinolaryngology Department, Konya, TURKEY. The congenital fistula of the oval window is a rarely clinical entity that needs to be diagnosed and treated promptly in order to cause, recurrent purulent meningitis. Case Presentation and Discussion: A case of a perilymph fistula from an oval window intraoperative detected in a 13-year-old male patient who had received medical treatment 3 times due to recurrent meningitis was presented. The patient was operated by us, the


pediatric infectious diseases clinic due to recurrent meningitis three times in a year and received hearing loss and imbalance complaints. As a result of the antibiotic treatment, the general condition of the child was improved, but the main goal was to discover the cause of recurrent meningitis. Immunological and genetic studies were performed, all of which were normal. On the otoscopic examination, the right tympanic membrane was in a minimal mate appearance and all other findings were normal. Right ear tympanometry was B / C. In MRI, large vestibular aqueductus was detected in mastoid cells in the right ear, along with findings of inflammation. The patient underwent an exploratory tympanotomy procedure. During surgery, it was observed that there was perilymph in the middle ear cavity and perilymph flow in the fistula in the middle of the oval window. The patient was operated 3 times because of recurrence of the fistula. In the last procedure, the right ear with total sensorineural hearing loss was completely obliterated and into closed cavity. Complications and meningitis were not detected at 6 months follow-up. Perilymph fistula a rare cause of recurrent meningitis, but may be the cause of recurrent meningitis, especially in children, as a secondary to congenital ear malformations. Diagnosis is intraoperative and definitive treatment is surgery, but revision surgery is usually required, especially due to the increase in cerebrospinal fluid pressures.

XI BALKAN CONGRESS OF OTORHINOLARYNGOLOGY  

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XI BALKAN CONGRESS OF OTORHINOLARYNGOLOGY  

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