Iranian Journal of Otorhinolaryngology
Volume:35 Issue: 1, Jan-Feb 2023

This study aimed to study the trend, histologic pattern, geographical distribution, and characteristics of nasopharyngeal carcinoma (NPC) and nasopharyngeal neoplasms (NPN) from 2003 to 2017 in Iran.

The Ministry of Health and Medical Education collected NPN cases from each province's corresponding university and stored them at Iran's National Cancer Registry (INCR) database. The Joinpoint program calculated the average annual percent change (AAPC) and its 95% confidence interval (CI). The jump model minimized the interfering effect of INCR transformation.

A total of 3653 NPN cases were reported between 2003-2010 and 2014-2017 with a mean age of 49.04 ± 18.31 years and a male to female ratio of 2.15. The age-standardized incidence rate (ASIR) per 100,000 person-years in 2017 was 0.30 and 0.68 for females and males, respectively. Although the ASIR/100,000 of NPN raised from 0.35 to 0.49 during 2003-2017, the trend was constant with a AAPC of -2% (95% CI: -4.8% to 0.9%). The age-specific incidence rate was highest in the older than 70 years-old population (1.56/100,000). NPC formed 77.1% of NPNs and showed a constant pattern (AAPC CI: -5.7% to 0.2%), in contrast to the significant increase of non-keratinizing squamous cell carcinoma (AAPC CI: 2.3% to 24.5%).

Nasopharynx cancer is rare in Iran, and NPC incidence remained constant during 2003-2017, unlike their rising trend previously reported. However, non-keratinizing squamous cell carcinoma exhibited a significant increase, and future studies are needed to examine the role of the Epstein-Barr virus on this growth rate.

The our aim was to research the occurrence of hearing loss associated with the effect of hypoxemia on inner ear structures owing to sleep apnea syndrome and to designate the timely signs of cochlear injury.
Participants diagnosed with probable sleep-disordered breathing among 63 patients, who experienced polysomnographic examination, were unexcluded in the present study. Control and study groups were structured in four groups pursuant to the apnea-hypopnea index and an intergroup comparison of audiometric parameters was performed. Accordingly, the apnea-hypopnea index, speech discrimination scores, speech recognition thresholds, and pure tone thresholds were compared.
A comparison of the obstructive sleep apnea groups by the degree of hearing loss indicated that there were significant differences by the average pure tone audiometry, average speech recognition thresholds, and average speech discrimination scores in both ears between the four groups (p<0.001).
The results of the study proposed that intermittent hypoxemia due to obstructive sleep apnea syndrome might have adverse effects on both the speech discrimination and hearing.

The pathophysiology of Chronic Rhinosinusitis is coordinated by distinct inflammatory reactions in different individuals. Inflammatory environments with a predominance of Th2 lymphocytes tend also to be rich in eosinophils. These environments are common during the formation of nasal polyps associated with aspirin intolerance, which is also marked by an increase in inflammatory mediators, especially IL-4, IL-5, and IL-13. Despite the significance of these inflammatory mediators, the relevance of IL-12 subunits' presence within eosinophilic nasal polyps, however, has been less studied. The current study aims to evaluate the presence of IL-12 subunits, IL-12p40 and IL-12p70, in eosinophilic nasal polyps and their correlations with IL-8 presence. We compared the concentrations of IL-8, IL12p40, and IL12p70 among samples of eosinophilic nasal polypoid tissue, eosinophilic nasal polypoid tissue associated with aspirin intolerance, and healthy nasal mucosa, using an indirect immunoassay (ELISA) kit.  When compared to healthy nasal mucosa, there was a lower concentration of IL-8 in Chronic Rhinosinusitis with Nasal Polyp (CRSwNP) tissue. Aspirin Intolerant polypoid tissue also presented a lower concentration of IL-12 subunits compared to healthy nasal mucosa. There was no significant correlation between IL-8 and IL-12 in the eosinophilic polypoid conditions.  In CRSwNP, there is a reduction in IL-8 and IL-12 subunits compared to control, with a lack of correlation between IL-12 and IL-8. The lack of correlation can be justified by a type two inflammatory storm environment.

Tinnitus can be associated with many auditory and non-auditory factors, and its prevalence varies widely in the literature. There is no large sample of published data on tinnitus prevalence and its associated factors in Iran. Here, we analyzed the PERSIAN Guilan Cohort Study (PGCS) data and reported the prevalence of tinnitus and some of the risk factors related to tinnitus in the Iranian population. This cross-sectional study was conducted on 10520 men and women between 35 and 70 years old. The prevalence of tinnitus and associations between tinnitus and age, sex, habitat, marital status, employment status, socioeconomic status, educational level, lifestyle habits, and comorbid diseases were examined using simple and multiple logistic regression analyses.The prevalence of tinnitus was 6.4% in this study. Based on the adjusted analysis, only older age (odds ratio: 2.60, 95% confidence interval: 1.88 – 3.60), residency in a rural area (odds ratio: 1.22, 95% confidence interval: 1.03 – 1.44), cigarette smoking (odds ratio:1.33, 95% confidence interval: 1.04 – 1.72), and having other comorbidities (odds ratio: 2.75, 95% confidence interval: 2.19 – 3.44) were related to tinnitus. In addition, the results of subgroup analyses by sex were mostly consistent with the overall analysis.Our results revealed that the prevalence of tinnitus in the north of Iran is comparable with other communities. Age and other comorbidities were among the most related factors to tinnitus.

Cervical adenopathy can be involved in various pathological processes. This study aimed to evaluate the ultrasound classification of cervical adenopathy (A-RADS) to choose the appropriate approach.

This cross-sectional study was conducted among 294 patients with cervical adenopathy at Mashhad University of Medical Sciences during 2020-2021. The data of the long axis diameter, short axis diameter, shape, border, vascular pattern, presence of calcification and changes in cyst/necrosis, cortical echogenicity, hilum visibility, and location of involved lymph nodes were extracted. Lymph nodes was classified into four normal, reactive, suspicious & lymphoid disorders, and metastatic groups, based on ultrasound appearance (Adenopathy-reporting and data system). Diagnostic methods included follow-up, core needle biopsy (CNB), and fine needle aspiration (FNA), and surgical results. After determining the final diagnosis, demographic, sonographic, and pathological data were analyzed at a significance level of p<0.05.

Of 294 patients, 185 were benign, and 109 were malignant. There were no significant differences in the location, long axis diameter, shape, cystic or necrotic changes, calcification, and margins of the lymph nodes between the benign and malignant groups. The enlarged short axis diameter, invisible hilum with isoechoic cortex, and non-hilar vascularity were significantly higher in the malignant group (p<0.001). The malignancy rate was 8.7% in reactive cases, 48.5% in lymphoid disorders, and 90% in metastatic nodes.

The results of this study shows that cervical lymph nodes can be classified based on short axis diameter, cortex and hilum echo-texture and vascular pattern into normal, reactive, suspicious & lymphoid disorders, and metastatic, which have a high concordance with pathologic results.

The quality of the surgical field during the surgery is impaired when bleeding occurs. This study compared the effect of tranexamic acid and dexmedetomidine on the rate of bleeding during endoscopic sinus surgery (ESS).

In this one-blind clinical trial, 72 patients with chronic rhinosinusitis who were candidates for ESS at Be’sat Hospital in Hamedan were randomly assigned to two groups. Group A received dexmedetomidine at a dose of 1μg/kg, and group B received tranexamic acid at a dose of 10mg/kg immediately after induction of anesthesia intravenously within 15 minutes. The two groups were evaluated and compared regarding the quality of the surgery field with the Boezaart scale, volume of intraoperative bleeding, hemodynamic changes, and complications up to 90 minutes after the beginning of surgery.

The mean volume of intraoperative bleeding in group A (181.67±86.66) was significantly higher than in group B (110.28±61.23) (P =0.000). At 15, 30, and 60 minutes, the quality of the surgical field in group B was better than group A (P =0.038), while at 90 minutes, there was no statistically significant difference (P =0.450). The mean arterial pressure in group A at 15 minutes was higher than in group B (P=0.003); at 60 and 90 minutes, it was lower, and the difference was statistically significant (P =0.01). On the other hand, in 30 minutes, the mean arterial pressure in group A was higher than in group B, without a significant difference (P =0.07). Moreover, there was no statistically significant difference between the average surgery time (P = 0.25) and the frequency of complications (P =0.405).

Based on the results, tranexamic acid is preferable to injectable dexmedetomidine to control and reduce bleeding during ESS.

To present a complex case of giant meningoencephalocele after a canal wall down mastoidectomy and describe our preferred approach to repair meningoencephalic herniation of the temporal bone.

Case Report:

A 20-year-old patient, who had previously undergone type III tympanoplasty with total ossicular reconstruction prosthesis for an attic cholesteatoma, presents with clinical and imaging features compatible with the diagnosis of a giant temporal meningoencephalocele. We performed a combined approach –transmastoid plus minicraniotomy- to repair the skull base defect. A multilayer reconstruction of the defect with septal cartilage and temporal fascia was performed. After a 48 months follow-up, the patient remains symptom free without signs of tissue herniation.

Transmastoid plus minicraniotomy combined approach is a safe and feasible technique in case of large and anterior skull base defects with low surgical morbidity, allowing a safe and multilayered reconstruction, even in the context of a simultaneous active chronic otitis media.

Primary nasopharyngeal tuberculosis (NPTB) is a rare disease but should not be missed as one of the differential diagnoses for cervical lymphadenopathy or nasopharyngeal mass. 

Case Report:

We describe a case of a 38 year old lady, who presented with bilateral cervical lymphadenopathy associated with intermittent fever. Nasoendoscopy examination and computed tomography scan of the neck revealed a centrally located mass predominantly at the left posterior nasopharyngeal wall without obliteration of both fossae of Rosenmuller. Typical histopathological features of necrotizing granulomatous lymphadenitis together with the common clinical presentation of cervical lymphadenopathy and nasoendoscopy findings of nasopharyngeal mass conclude the diagnosis of nasopharyngeal tuberculosis. With anti-tuberculous therapy, the cervical lymphadenopathy and nasopharyngeal mass were completely resolved.

Nasopharyngeal tuberculosis is an uncommon disease with great diagnostic challenges and with early diagnosis and adequate treatment, NPTB carries a good prognosis with complete disease resolution.

Lipomas of the of the head and neck region are rare, more so in the retropharyngeal space. Lipomas in this region can produce symptoms that demand surgical excision. This paper describes a case of lipomatous hamartoma of the retropharynx, which to the best of our knowledge has not yet been reported in English literature.

 Case Report:

 A 53-year-old gentleman presented to the ENT department with snoring, voice change and stridor. Examination revealed a smooth bulge in the posterior wall of the oropharynx causing near complete obstruction of the airway. A contrast enhanced computed tomogram revealed a non-enhancing hypodense lesion in the retropharyngeal space extending from C1-C4 level, which was suggestive of a lipoma. The tumour was surgically excised trans-orally. A limited review of literature is also presented. 

Trans-oral approach is preferred to external approach for surgical removal of benign retropharyngeal tumours that cause obstructive symptoms, as our case. This approach is safe, effective, and associated with lesser post-operative morbidity.

Primary hyperparathyroidism due to parathyroid adenoma commonly causes raised serum calcium and focal giant cell lytic lesions in bones known as Brown’s tumors. It is more common in females in the post-menopausal age group.

Case Report:

We report a case of a 29-year-old female patient with Brown’s tumor maxilla in a clinical setting of normocalcemic primary hyperparathyroidism. The patient presented to us with facial and palatal swelling for which FNAC was done. Cytology revealed hemosiderin-laden macrophages suspicious for Brown’s tumor. On further imaging studies such as CT Neck, Tc99 Sestamibi scan, and other biochemical tests like parathyroid hormone assay and serum calcium level, the diagnosis of a hyperfunctioning parathyroid gland with normal calcium level was made. Parathyroidectomy was performed and parathyroid adenoma came out to be the primary pathology. On post-operative follow up there was regression of the swelling on the face and palate relieving the patient symptomatically.

The diagnostic suspicion of primary hyperparathyroidism should be kept in mind whenever a young female presents with suspected Brown’s tumor, even with normal serum calcium levels, for appropriate management. Ours was a highly uncommon case that was a diagnostic challenge and had a successful treatment outcome. Very few such cases have been reported in the literature to date to the best of our knowledge.