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We performed a review of recent literature in order to present new insights in pathophysiology, symptomatology, diagnostics and therapy of laryngopharyngeal reflux (LPR). Although the number of LPR studies has increased significantly over the past few years, there are still no gold standards or standardized protocols for diagnosing and treating LPR, and an interdisciplinary approach is necessary. Questionnaires for symptom severity self-assessment and clinical signs should include both symptoms and signs of gastroesophageal reflux disease and respiratory system, and primary objective diagnostic tool should be a simple determination of the most reliable biomarker pepsin, from easily obtainable fluid, such as saliva. Unclear cases should be referred for further assessment with multichannel impedance and pH monitoring. It allows the determination of the type of reflux (acidic, mixed and non-acidic) and implementation of personalized therapy. According to the latest findings, behavioural therapy would be the method of choice in the treatment of mild forms of the LPR. In moderate and severe forms, the combination of drugs depends on the reflux type. Drug therapy should be carried out for a minimum of eight weeks, optimally three months, followed by follow-up examination and revision of symptoms and clinical findings. Significant improvement allows drug therapy reduction, while cases with slight improvement demand dosage increase and another three months of treatment. In cases without change or possible deterioration, patients should undergo additional gastroenterological work-up and potential surgical treatment. Strict adherence to behavioural measures is proposed, while long-term prescription of proton pump inhibitors is not recommended given the proven number of adverse drug reactions.

Lateral lymph node metastases occur in 30–80% of papillary thyroid carcinoma patients. It is generally accepted that they do not impact the overall survival but are identified as an independent risk factor for locoregional recurrence. However, their significance is still not clearly understood. The aim of this study is to analyse metastasizing to the lateral neck levels in a cohort of patients with papillary thyroid carcinoma and lateral neck metastases, and also to assess the recurrence rate through regular check-ups. Methods: We prospectively analysed the data of 135 patients who underwent total thyroidectomy with selective neck dissection (levels II–VI), from 2011 to 2020. We analysed demographics and clinical characteristics of patients and assessed their correlation. Patients were followed up until April 2021. The median follow-up period was 62 months. Patients were followed up through regular check-ups and hospital records. Results: The median age was 36.8 years, 28 percent were men. The most frequently affected neck levels were III, IV, II, and V, respectively. Primary tumours larger than one cm displayed a higher number of positive lymph nodes, while extracapsular spread was revealed to be an independent risk factor for a higher number of positive lymph nodes. During a median follow-up period of 62 months, 18 (13.3%) patients developed regional recurrence of the disease, while two patients (1.2%) developed distant metastases.The mean disease-free period was 16.7 months. Conclusion: Lateral neck metastases occur in predictable patterns. The most frequently affected neck level was III, followed by IV. In two-thirds of the patients, metastases were found in multiple lateral neck levels. Tumour size and extracapsular spread show association with a higher number of positive lymph nodes, and with the higher number of positive nodes in patients with extracapsular spreading. Considering the recurrence rate in the follow-up period, we can conclude that selective neck dissection of levels II–VI proved to be an optimal treatment modality for such patients.

Ciljevi: Cilj ovog istraživanja bio je prikazati utjecaj pandemije COVID-19 na rad Klinike za bolesti uha, nosa i grla i kirurgiju glave i vrata KBC-a Zagreb. Metode: Iz računalne baze podataka KBC-a Zagreb te baze onkoloških bolesnika Klinike retrospektivno su izvučeni te uspoređeni podatci o izvršenim postupcima i dijagnozama u razdoblju prva četiri mjeseca 2019., 2020. te 2021. godine. Rezultati: Ukupan je broj slučajeva 2020. bio veći za 32,4%, a 2021. za 13,19% (p, Aim: The aim of this study was to show changes in the work of the Ear, Nose, Throat and Head and Neck Surgery Department, UHC Zagreb, during the COVID-19 pandemic. Methods: We retrospectively extracted and compared the data on the procedures and diagnoses of the Department during the period from January 1st to April 30th in 2019, 2020 and 2021. Results: The total number of cases was lower by 34.2% in 2020, and by 13.19% in 2021, compared to 2019 (p

Cervical lymph node metastases are frequently found in papillary thyroid carcinoma (PTC) and occur in a stepwise fashion. Skip metastases that omit the central compartment and spread initially in lateral neck levels are present in a certain share of patients, and their significance is poorly understood. The aim of this prospective study was to identify their possible predictors and clinicopathological factors in a group of patients with PTC with lateral lymph node (LLN ) metastases. Methods: We enrolled 68 patients with PTC with preoperatively evaluated LLN metastases who underwent total thyroidectomy with lateral lymph node dissection between 2011 and 2018. We analysed the clinicopathological features and pattern of dissemination of continuous and skip metastases. Results: The prevalence of skip metastases was 23.5%. Compared with the continuous metastases group, the patients were older, had primary tumors that were more often situated unilaterally, and had smaller primary tumor size. Level II was less often involved, and none of the patients with skip metastases had all LNN positive (p = 0.05). Conclusion: Skip metastases occur more frequently in older patients and display certain clinicopathological features like smaller size of the primary tumor and dissemination in less lateral neck levels. In the view of the fact that they are found rather frequently, lateral neck regions should be meticulously investigated in patients with PTC without central lymph node (CLL ) metastases., Metastaze u limfnim čvorovima vrata čest su nalaz kod papilarnog karcinoma štitnjače i pojavljuju se određenim redoslijedom. Tzv. „skip“ metastaze koje “preskaču” centralni odjeljak te se šire inicijalno u lateralne regije vrata mogu se naći u određenom broju tih pacijenata, a njihov značaj nije još dobro istražen. Cilj ove prospektivne studije jest identificirati njihove moguće prediktore i kliničko-patološke značajke u skupini pacijenata s lateralnim metastazama papilarnog karcinoma štitnjače. Metode: U studiju je bilo uključeno 68 pacijenata s papilarnim karcinomom kojima su prethodno verificirane lateralne metastaze te su bili podvrgnuti totalnoj tiroidektomiji uz lateralnu disekciju vrata, u razdoblju od 2011 do 2018 godine. Analizirane su i uspoređene kliničko-patološke značajke te obrazac metastaziranja kontinuiranih i skip metastaza. Rezultati: Učestalost skip metastaza bila je 23,5%. U usporedbi sa skupinom s kontinuiranim metastazama, ti pacijenti bili su stariji, primarni tumori bili su rjeđe bilateralni, te su bili manjih dimenzija. Regija II bila je rjeđe zahvaćena, te nitko od tih pacijenata nije imao sve regije zahvaćene metastazama. Zaključak: Skip metastaze pojavljuju se češće u starijih pacijenata te pokazuju određene kliničko-patološke značajke kao što su manja dimenzija primarnih tumora, te diseminacija u manje lateralnih regija vrata. Uzevši u obzir da se takve metastaze relativno često susreću, lateralne regije vrata trebale bi se temeljito istražiti u pacijenata s papilarnim karcinomom štitnjače bez metastaza u centralnim odjeljcima vrata.

Autologous fat vocal fold augmentation is a widespread surgical procedure that aims to repair glottal incompetence in patients with unilateral vocal fold paralysis (UVFP). However, there are some concerns in the literature about the long-term results of this technique. At the ENT Department of the Zagreb University Hospital Centre, this technique has been in use for more than 15 years, and a retrospective medical chart review was conducted from June 2005 to November 2019. Overall, 78 patients with UVFP met the inclusion criteria for enrolment in the study. All patients underwent at least one preoperative and two postoperative voice assessments, one early (within 3 months from surgery) and one late (at least 1 year after surgery). All tested voice outcome parameters (maximum phonation time (MPT), jitter, shimmer, noise-to-harmonic ratio (NHR )) significantly improved after surgery, both early and late postoperatively (p, Augmentacija autolognog masnog tkiva u glasnice široko je rasprostranjen kirurški postupak koji se koristi u liječenju fonatorne glotidne insuficijencije kod pacijenata s jednostranom paralizom glasnice. Međutim, u literaturi postoje određene dvojbe oko dugoročnih rezultata ove tehnike. U Klinici za bolesti uha, nosa i grla i kirurgiju glave i vrata KBC-a Zagreb ovom se tehnikom služimo već više od 15 godina te smo proveli retrospektivnu analizu povijesti bolesti bolesnika s jednostranom paralizom glasnice od lipnja 2005. do studenog 2019. Sveukupno je 78 bolesnika ispunjavalo kriterije za ulazak u studiju. Kod svih bolesnika učinjena je barem jedna predoperativna i dvije postoperativne objektivne analize glasa, jedna rana (unutar 3 mjeseca od operacije) i jedna kasna (najmanje 1 godinu nakon operacije). Svi testirani parametri analize glasa (maksimalno vrijeme fonacije (MPT), jitter, shimmer, omjer šuma i harmonika (NHR )) značajno su poboljšani nakon operacije i rano postoperativno i kasno postoperativno (p < 0,001). Stopa reoperacija u ovom uzorku bila je samo 10,3 % (8/78), tako da je većina pacijenata obuhvaćena ovim istraživanjem imala dugoročno poboljšanje glasa nakon ovog kirurškog zahvata. Prema rezultatima našeg istraživanja, augmentacija autolognog masnog tkiva u glasnice vrlo je korisna i učinkovita kirurška tehnika s dugotrajnim rezultatima kod većine pacijenata s jednostranom paralizom glasnice.

Operacije štitnjače danas su među najčešćim kirurškim postupcima otorinolaringologa, s vrlo niskom stopom postoperativnih komplikacija. Opseg kirurškog zahvata, kao i manipulacije oko susjednih laringalnih struktura, prvenstveno oko povratnog laringalnog živca, najznačajniji su čimbenik rizika za razvoj komplikacija. Poremećaji gutanja učestali su nakon kirurgije štitnjače, iako su često neprepoznati od strane kliničara. Pregledom literature uočili smo da su disfagija i disfonija, koje su posljedica oštećenja povratnog i gornjeg laringalnog živca, u dosadašnjim istraživanjima dobro istražene, dok etiologija poremećaja gutanja u bolesnika nakon nekomplicirane tireoidektomije nije jasna. Većina bolesnika nakon tireoidektomije ima smetnje gutanja u ranom postoperativnom razdoblju, pri čemu bolesnici vrlo često spontano razvijaju kompenzatorne mehanizme kojima si olakšavaju tegobe, a i tijekom 3 mjeseca većina tegoba spontano nestaje. Međutim, 20% bolesnika ima smetnje gutanja koje dugoročno pogoršavaju njihovu kvalitetu života. Simptomi su često nespecifični: osjećaj otežanog gutanja, napetost u grlu ili bol pri gutanju. Do danas ne postoje standardizirani protokoli dijagnostičkih, niti terapijskih postupaka u rješavanja disfagije nakon nekomplicirane kirurgije štitnjače. U dosadašnjim istraživanjima najčešće je korišten upitnik Indeks poremećaja gutanja (SIS- 6). SIS-6 sadrži 6 izjava koje opisuju najčešće simptome koje bolesnik vrednuje od 0 do 4, ovisno o težini simptoma koje osjeća. Upitnik je brz i jednostavan, te je lako primjenjiv u svakodnevnoj kliničkoj praksi, kako za otkrivanje, tako i za praćenje bolesnika. Također ne postoji zlatni standard u instrumentalnoj dijagnostici kojim bi se potvrdila dijagnoza i pojasnila etiologija disfagije nakon nekomplicirane tireoidektomije. Dosadašnja istraživanja pokazala su da je fiberoptička endoskopija grkljana neophodna prije i nakon operacije štitnjače radi identifikacije promjena pokretljivosti glasnica, dok su videofluoroskopijom gutanja i manometrijom jednjaka uočene disfunkcija gornjeg sfinktera jednjaka i poremećaj motiliteta proksimalnog dijela jednjaka.

Objective: This is the first histopathologic study that investigates the incidence of the pneumatized crista galli. Study design: A prospective histopathologic study. Setting: Tertiary academic medical center. Subjects and methods: A total of 109 specimens of crista galli were obtained postmortem during 2018 from randomly chosen patients who died at the University Hospital Centre Zagreb and had an autopsy at our Department of Pathology and Cytology. Specimens were surgically resected during the autopsy and then fixed, decalcinated, dehydrated, and embedded in paraffin. All slides were cut into 5-µm-thin sections and stained with a standard method (hematoxylin and eosin) for light microscope analysis. Specimens were histopathologically analyzed for the existence of pneumatization inside crista galli. The criterion to declare a specimen pneumatized was the presence of mucosa inside the cavity. Results: Pneumatized crista galli was found in 5 of 109 specimens (4.59%). In 5 of 5 cases (100%) of pneumatized crista galli, there was evidence of chronic inflammation. Conclusion: We found that the incidence of pneumatized crista galli is significantly lower in our histopathologic study in comparison with the majority of previous radiologic studies. Our study also found that all 5 specimens with pneumatized crista galli had chronic inflammation in the mucosa, which is a considerably higher incidence than in the previous studies (7.7%-44%). Due to the emerging evidence of pneumatized crista galli being of clinical importance, we suggest that a larger study be conducted before the results are generalized to the general population.

This study aims to provide insight into the etiology and frequency of swallowing complications that arise after thyroidectomy and to outline the available diagnostic procedures by revising the existing literature on this topic. We conducted a bibliographic search using the electronic database MEDLINE /PubMed to identify all relevant articles and 44 studies were included in the review out of a total of 218 published articles. Dysphagia after thyroid surgery is a common postoperative complication which, in the short- or long-term, significantly affects patient life quality. There is no standard diagnostic protocol for thyroidectomy-related swallowing impairment. Among the reviewed studies, 8 questionnaires and 12 instrumental diagnostic tools were used to identify swallowing difficulties related to thyroid surgery. The Swallowing Impairment Index (SIS-6) was the most-used questionnaire. Fiberoptic endoscopy is a standard diagnostic tool performed prior and after thyroid surgery, primarily to identify changes in vocal fold mobility. Although instrumental findings usually reveal non-specific alterations of swallowing; swallowing videofluoroscopy and esophageal manometry can be the most helpful tools in further management of thyroidectomy dysphagia. In patients with thyroidectomy-related swallowing difficulties and suspected laryngopharyngeal reflux, 24-hour MII - pH metry should be performed., Kako bismo dali bolji uvid u etiologiju i učestalost komplikacija gutanja koje su posljedica tireoidektomije te prikazali dostupne dijagnostičke postupke, proveli smo bibliografsku pretragu koristeći elektroničku bazu podataka MEDLINE / PubMed. Od ukupno 218 objavljenih članaka, u recenziju su bile uključene 44 studije. Disfagija nakon operacije štitnjače uobičajena je postoperativna komplikacija koja, kratkoročno ili dugoročno, značajno utječe na kvalitetu života pacijenta. Ne postoji standardni dijagnostički protokol za oštećenje gutanja povezano s tireoidektomijom. U studijama uključenim u pregled literature korišteno je 8 upitnika i 12 instrumentalnih postupaka za dijagnosticiranje poremećaja gutanja povezanih s operacijom štitnjače. Indeks poremećaja gutanja (SIS -6) bio je najčešće korišteni upitnik. Fiberoptička endoskopija standardni je dijagnostički postupak koji se provodi prije i nakon operacije štitnjače, prvenstveno radi identifikacije promjena pokretljivosti glasnica. Iako su nalazi instrumentalnih dijagnostičkih postupaka obično nespecifični, videofluoroskopija gutanja i manometrija jednjaka daju najviše relevatnih podataka. U bolesnika s poteškoćama gutanja i sumnjom na laringofaringealni refluks potrebno je provesti 24-satnu MII pHmetriju.

Objective: To investigate the role of matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) in the development of cervical metastases in papillary thyroid cancer. Our hypothesis is that level of expression of MMPs and TIMPs is associated with the development of cervical metastases and the pattern of metastatic process in papillary thyroid cancer. Design: This research retrospectively investigates the expression of MMP-1, -2 and -9 as well as TIMP-1 and -2 in papillary thyroid carcinoma tissue. Tissue specimens were immunohistochemically treated with primary monoclonal antibodies against MMP-1, MMP-2, MMP-9, TIMP-1 and TIMP-2. Setting: Single-centre study. Participants: In total, samples of 159 patients were analysed. In all patients, total thyroidectomy was performed, whereas 102 patients underwent selective neck dissection of either central (level VI) or lateral neck (level II-V). Subjects were divided into four groups. Main outcome measures: Matrix metalloproteinases and TIMPs expression values were analysed in each group, and groups were compared to each other. Results: Total number of patients was 159, of which 125 were women and 34 men. Comparing expression levels of MMPs and TIMPs in metastatic (study groups) and non-metastatic (control group), papillary thyroid carcinomas yielded significant differences in MMP-1 and TIMP- 1 expression levels, where the highest expression values were found in the group with metastasis in lateral neck. Expression levels of MMP-2, MMP-9 and TIMP-2 did not differ statistically significant among the groups. Conclusion: Elevated expression of MMP-1 and TIMP- 1 in tumour tissue can be considered a predictive factor for the development of metastases.

Paranasal sinus osteomas are mostly asymptomatic; however, secondary mucocele can develop if they impede the natural sinus drainage. Such a mucocele can destroy the bone and extend into the adjacent structures. We report on an unusual case of frontal sinus osteoma in a 27-year-old patient, complicated by large secondary mucocele that eroded the bone and extended into the frontal lobe of the brain. Unexpectedly, the patient did not report any visual or other symptoms attributable to central nervous system deficit. The mucocele was completely resected through bifrontobasal osteoplastic craniotomy, whereas osteoma was evacuated in its entirety by both drilling and mobilizing. Open surgical approach remains the main treatment for complicated paranasal sinus osteoma, and radical removal of intracranial mucocele is mandatory to prevent the development of life-threatening infections. Although intradural extension of a secondary mucocele is extremely unusual, head and neck surgery specialists should take this severe complication in consideration.

The objective of this study is to evaluate the efficacy of the Harmonic ACE™, Harmonic FOCUS™ and harmonic scalpel with 5-mm curved blade in head and neck surgery. During a 15-month period, we performed 295 thyroidectomies, 23 parotidectomies and 45 tonsillectomies using the harmonic scalpel. Control group consisted of 106 thyroidectomies, 9 parotidectomies and 30 tonsillectomies performed with the use of conventional hemostatic techniques. The use of both Harmonic ACE™ and Harmonic FOCUS™ scalpel reduced the time of thyroid and parotid surgery by 20–25%. The use of Harmonic ACE™ reduced the mean time of tonsillectomy, while the use of 5-mm curved blade had no significant effect. Postoperative pain and complication rate were comparable for both the groups. In conclusion, the use of both Harmonic ACE™ and Harmonic FOCUS™ devices significantly reduces operative time in the head and neck procedures and enables a smaller neck skin incision in thyroidectomy.

Objectives: The superficial layer of deep cervical fascia represents a valuable material for the reconstruction of defects secondary to partial vertical laryngeal resections. However, there are drawbacks to the use of this flap, which include possible weakness and subsequent instability of the laryngeal wall. Methods: To overcome this problem, we included platysma along with the superficial layer of deep cervical fascia to form a composite soft tissue flap that will meet all reconstructive needs following partial vertical laryngeal resection. Results: Inclusion of platysma yields more durable and adequately vascularized flap resistant to saliva, seroma formation, and infection. Because of segmental blood supply of strap muscles and their indirect perforating vessels, medially based horizontal composite flap is better supplied with blood in comparison with cranially based vertical flap. Medial insertion of the horizontal flap is much more convenient than lateral, due to ancillary blood supply from the contralateral side and easier pursuance of ipsilateral neck dissection. Conclusions: The method of our choice for laryngeal reconstruction after partial vertical laryngeal resections is paramedially based horizontal platysmofascial composite flap with the insertion opposite to the side of the primary laryngeal tumor.

Inverted papilloma is generally considered a benign unilateral sinonasal tumor. Its synchronous bilateral multicentric occurrence is extremely rare. A 22-year-old male patient presented with stage III inverted papilloma involving both ethmoid sinuses, both frontal sinuses, and cribriform area. The patient also had a large osteoma emanating from the basal part of the frontal sinus septum, which completely obstructed both nasofrontal recesses, leaving no communication between the sinuses and the nasal cavity. The frontal sinus septum was intact, so there was no communication between the 2 sides either. Following the era of aggressive surgical approaches dominated by lateral rhinotomy and medial maxillectomy, the advent of endoscopic techniques has dramatically improved visualization of sinus chambers and nasal cavity, resulting in lower morbidity and similar results to those achieved with open surgical procedures. In our patient, the concomitant presence of a huge frontal sinus osteoma posed an unacceptable risk for endoscopic resection due to the possible residual disease in the nasofrontal recess regions. Surgical resection remains the mainstay treatment and should be tailored in accordance with the localization and spread of disease. The surgeon should be ready to use different surgical approaches and, if intraoperatively needed, to modify them accordingly.

Endoscopic CO 2 laser surgery (ELS) is a widely accepted treatment modality for early laryngeal cancer. Commonly re- ported advantages of ELS are good oncologic results with low incidence of complications. Although less common if com- pared with open procedures, complications following ELS can be very serious, even with lethal outcome. They can range from intraoperative endotracheal tube fire accidents to early and late postoperative sequels that require intensive medical treatment, blood transfusion, or revision surgery. We present our institutional experience, discuss the possible complica- tions of ELS for laryngeal cancer, and outline the concepts of their treatment, with comprehensive literature review. Com- plications are more frequent following the treatment of supraglottic as compared to glottic cancer. If compared with open surgery, ELS for laryngeal cancer is associated with a lower incidence of complications. Every surgeon performing ELS should comply with particular strategies to avoid complications in the first place, and have a clear concept of their management if they occur.

Objective:Nasopharyngeal tuberculosis is a rare condition, even in endemic tuberculosis areas. We report a case of primary nasopharyngeal tuberculosis from a non-endemic area, which presented with symptoms resembling exacerbation of previously diagnosed chronic rhinosinusitis.Case report:A 48-year-old man presented with extreme postnasal drip and an unpleasant nasal odour. Endoscopic examination revealed irregular thickening of the left lateral and posterior wall of the nasopharynx, partially covered with crusts and necrotic tissue. Histopathological study showed typical giant cell epithelioid granulomas with caseous necrosis. Direct examination after Ziehl–Neelsen staining was positive for tuberculosis. After six months of antituberculous triple therapy, endoscopic examination revealed a completely normal nasopharynx.Conclusion:To our best knowledge, this is the first published report of primary nasopharyngeal tuberculosis in a patient previously diagnosed with chronic rhinosinusitis. The difficulties in obtaining a proper diagnosis in such a case are discussed.

The superficial layer of deep cervical fascia represents a valuable material for the reconstruction of defects secondary to partial vertical laryngeal resections. However, there are drawbacks to the use of this flap, which include possible weakness and subsequent instability of the laryngeal wall.To overcome this problem, we included platysma along with the superficial layer of deep cervical fascia to form a composite soft tissue flap that will meet all reconstructive needs following partial vertical laryngeal resection.Inclusion of platysma yields more durable and adequately vascularized flap resistant to saliva, seroma formation, and infection. Because of segmental blood supply of strap muscles and their indirect perforating vessels, medially based horizontal composite flap is better supplied with blood in comparison with cranially based vertical flap. Medial insertion of the horizontal flap is much more convenient than lateral, due to ancillary blood supply from the contralateral side and easier pursuance of ipsilateral neck dissection.The method of our choice for laryngeal reconstruction after partial vertical laryngeal resections is paramedially based horizontal platysmofascial composite flap with the insertion opposite to the side of the primary laryngeal tumor.

Genital human papillomavirus (HPV) infections are among the most common sexually transmitted diseases. HPV is associated with a spectrum of diseases ranging from benign vulgar verrucae and condylomata accuminata to malignant cancers of the cervix, vulva, anus and penis. Genital HPV is in most cases transmitted sexually, but non-sexual routes of transmission, such as perinatal and autoinoculation, are possible. Men can be a reservoir of the virus that lives in latent or subclinical form on genital mucosa. Such an asymptomatic infection may be an oncogenic factor in the development of cervical cancer. Colposcopic examination of the genitalia after the application of 3–5% acetic acid is a reliable method for the identification of subclinical HPV infection. Successful therapy of anogenital warts is characterized by their complete clearance, as well as by the lack of recurrence. Current treatments do not reliably eradicate HPV infections. The diagnosis and therapy of HPV infection in men is potentially beneficial because the eradication of penile HPV infection may decrease the reservoir of the virus.