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OBJECTIVE To update tonsillectomy incidence rates in Denmark and identify whether the incidence rates vary between geographical areas in the country during the period 1991-2012. DESIGN This was a retrospective nationwide cohort study using data from the comprehensive Danish patient registries. Data included surgical code, gender and date of birth, date and place of surgery. SETTING Hospitals and private oto-, rhino-, laryngology (ORL) offices. PARTICIPANTS Danes who underwent tonsillectomy in the period 1991-2012. MAIN OUTCOME MEASURE Tonsillectomy. RESULTS In the 22-year period, 177 211 tonsillectomies were conducted, and the overall incidence of tonsillectomy decreased significantly over time. The overall annual incidence of tonsillectomies decreased from 155.7 per 100 000 inhabitants in 1991 to 129.4 per 100 000 inhabitants in 2012. In 1991, 5.5% of tonsillectomies were performed in office settings, while in 2012, it had increased to 26.6% (P

Our findings that the microbiome differs between crypts of the adenoids and crypts of the palatine tonsils, including the relative abundances of potential pathogens such as Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis, may be the stepping stone for further investigation of individual microbiomes in a longitudinal design that includes recording of the fluctuating health status of the child. Such studies may have the potential to lead to new preventive measurements such as implantation of protective nonpathogens at the nasopharynx as an alternative to adenoidectomy., Acute otitis media (AOM), secretory otitis media (SOM), and acute pharyngotonsillitis are the most frequent reasons for visits to general practitioners, pediatricians, and otolaryngologists. Microbial colonization of the epithelial lining of Waldeyer’s lymphatic tissues, consisting of the palatine tonsils, lingual tonsils, adenoids, and Eustachian tube tonsil, is a well-known clinical challenge during infancy due to frequent episodes of upper respiratory tract infections. However, no previous studies have investigated the combined role of the palatine tonsils and the adenoids as a reservoir for pathogens associated with SOM in small children. We analyzed the combined crypt microbiome of the palatine tonsils and adenoids from 14 small children with hyperplasia of the tonsils or adenoids and 14 small children with SOM using 16S rRNA gene pyrosequencing. Our study demonstrated a significant difference between the microbiome of the adenoids and that of the palatine tonsils in the two groups but not between the two anatomical locations within the two groups. In particular, the potential pathogens Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis were almost exclusively found in the adenoids of both patient groups, indicating that the adenoids and not the palatine tonsils are the main reservoir for potential pathogens leading to AOM and SOM. IMPORTANCE Our findings that the microbiome differs between crypts of the adenoids and crypts of the palatine tonsils, including the relative abundances of potential pathogens such as Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis, may be the stepping stone for further investigation of individual microbiomes in a longitudinal design that includes recording of the fluctuating health status of the child. Such studies may have the potential to lead to new preventive measurements such as implantation of protective nonpathogens at the nasopharynx as an alternative to adenoidectomy.

Background and aim: Atherosclerosis evolves or accelerates when arteries are exposed to ionizing radiation, both early and late after exposure. Radioiodine therapy of benign thyroid disease exposes the carotid arteries to 4–50 Gy, and may thereby increase the risk of atherosclerosis. Increased risk of cerebrovascular events has been reported after radioiodine therapy. This study aimed to examine whether atherosclerosis develops early or late after radioiodine therapy of benign thyroid disease. Method: Patients treated for benign thyroid disorders (nontoxic goiter, adenoma, and hyperthyroidism) were examined with ultrasound for the main outcome, carotid intima media thickness (CIMT), and for plaque presence (plaque presence only in late damage). Signs of early damage from radioiodine were studied in 39 radioiodine-treated patients, who were examined before treatment and at 1, 3, 6, and 12 months after treatment. Late changes were studied in a cross-sectional case-control design, with radioiodine-treated patients as cases (n = 193) and patients treated with surgery as controls (n = 95). Data were analyzed with repeated measurement for longitudinal data, and with multivariate regression for cross-sectional data. Results were adjusted for age, sex, cholesterol, smoking status, known atherosclerotic disease, and body mass index. Results: No changes in CIMT were found in the patients followed prospectively for one year after treatment with radioactive iodine for benign thyroid disease (p = 0.58). In the study on late effects, there was no difference in CIMT (p = 0.25) or presence of plaques (p = 0.70) between those treated with radioactive iodine and those treated with surgery (9.8 and 5.6 years since treatment, respectively). Furthermore, the level of thyrotropin (TSH) did not influence these atherosclerosis markers. Conclusion: No early changes in CIMT were detected in patients treated with radioactive iodine for benign thyroid disease. No signs of late effects of radioactive iodine on CIMT or plaque presence were found after 10 years of follow-up. The radiation to the carotid arteries by radioactive iodine therapy for benign thyroid disease may therefore have no or low effect on atherosclerotic burden of the carotid arteries in general.

Objective The primary aims were to determine the rates of and prognostic factors for overall survival, disease-specific survival and disease-free survival following salvage total laryngectomy. Design Retrospective longitudinal study. Setting Tertiary medical centres. Participants A total of 142 patients in eastern Denmark undergoing salvage total laryngectomy for squamous cell carcinoma of the larynx or hypopharynx. Main outcome measures 5-year overall survival, 5-year disease-specific survival, 5-year disease-free survival and prognostic factors for these outcomes. Results 5-year overall survival, disease-specific survival and disease-free survival were 37.7%, 54.9% and 55.3%, respectively. N classification at primary diagnosis, lymph node excision and postoperative complications within 1 year after salvage total laryngectomy were prognostic factors for shorter overall survival, disease-specific survival and disease-free survival. Residual tumour/recurrence was negatively associated with overall survival, close or involved resection margins with disease-specific survival, and second primary cancer was associated with longer disease-specific survival and disease-free survival. Nine per cent of all patients had residual tumour and 33.8% developed a recurrence. Conclusion Our overall survival, disease-specific survival and disease-free survival findings are in accordance with previous studies. With the purpose of identifying recurrent tumour, we suggest extra attention being given to patients with higher N classification and need for lymph node excision during salvage total laryngectomy along with use of frozen sections. The high number of patients with recurrence within 1 year after salvage total laryngectomy occurred although thorough and regular follow-up visits were performed.

The objective of this study was to evaluate the use of LigaSure small jaws in superficial parotidectomy for blood loss, operative time and facial nerve function. This was a prospective non-randomized study of 35 patients with a benign parotid tumor. Sixteen patients had LigaSure small jaws parotidectomy, and 19 patients had cold knife parotidectomy. Operative time, blood loss, facial palsy and other complications were assessed. The use of LigaSure was associated with a significant reduction in mean operative time (128 min vs. 155, p = 0.04) and intraoperative blood loss (40 mL vs. 115 mL, p < 0.001). Transient facial weakness was seen in 4 of the 16 patients in the LigaSure group and in 1 of the 19 patients in the conventional group (p = 0.2). No significant differences were observed between the two groups with respect to hemorrhage, length of hospital stay, infection, wound healing, salivary fistula or seroma. LigaSure small jaws in parotidectomy results in significantly less blood loss and operative time compared to cold knife dissection.

To describe outcome and prognostic factors in a national Danish series of patients treated for salivary gland carcinoma. From three Danish nation-wide registries and supplementary patient records, 871 patients diagnosed with primary major or minor salivary gland carcinoma in the period from 1990 to 2005 were identified. A total of 796 (91%) histological specimens were revised according to the WHO 2005 classification. The median follow-up time was 78 months. Three hundred and thirty-four patients (38%) experienced recurrence. Crude survival, disease-specific survival and recurrence-free survival after 5 and 10 years were 66%, 76%, 64% and 51%, 69%, 58%, respectively. In multivariate analysis age, latency, stage, microscopic margins, vascular invasion and histological grade were all independent prognostic factors with regards to crude and disease-specific survival. Stage, microscopic margins, vascular invasion and histological grade were independent prognostic factors for recurrence-free survival. Age over 61 years, latency under 8 months, stage 3+4 disease, involved or close microscopic margins, vascular invasion and high histological grade are all independent prognostic factors with a negative impact on survival in salivary gland carcinoma patients. This knowledge can be helpful in guiding clinicians in daily work and choice of treatment across the large variety of salivary gland carcinoma subtypes.

microRNA (miRNA) expression profiling and classification of tissue obtained from fine-needle aspirates (FNA) could be a major improvement of the preoperative diagnosis of thyroid nodules.Before this can be clinically implemented, a robust and non-toxic method for obtaining sufficient quantity and quality of RNA from single in vivo FNA has to be established. RNAlater is a non-toxic RNA-stabilizing agent. However, due to the high density of RNAlater, pelleting of the tissue samples is difficult, and results in low recovery of RNA that is insufficient for subsequent miRNA array expression analysis. We therefore developed a simple centrifugation method for capturing tissue stored in RNAlater on a 0.45-μm filter.FNA from 24 patients with a solitary cold thyroid nodule was stored in Trizol, liquid nitrogen, or RNAlater. The tissue stored in RNAlater was either pelleted by centrifugation or captured on the 0.45-μm filters. RNA was extracted using the Trizol method. To validate results, FNA from additional 30 patients were analyzed based on the modified RNAlater protocol.Capturing FNA tissue samples on the filters increased the RNA yield 10 fold and maintained RNA purity, permitting miRNA array expression profiling and allowing comparable levels of known miRNA-clusters regardless of preservation technique. Results were confirmed in an additional 30 patients.The modified RNAlater protocol is well suited for isolating RNA from single thyroid in vivo FNA in a clinical setting. Furthermore this permits shipping of FNA samples at room temperature from peripheral centers to a centralized array core facility.

A 26-year-old male with a 10-year history of complete selective IgA deficiency and recurrent autoimmune anaemia and thrombocytopenia (Evans syndrome) is presented. Both serum IgA and saliva secretory IgA were below the detection limit (less than 0.05 mg/l). No other features of autoimmunity were seen. The patient had a normal % of peripheral blood lymphocytes with surface IgM and IgG cells and normal in vitro lymphocyte transformation after stimulation with mitogens and antigens. The pleomorphic and randomly appearing immunologic features of selective IgA deficiency are emphasized by the present case.

Introduction. Papillary microcarcinomas (PMC) of the thyroid gland are defined according to The WHO Committee as papillary carcinomas measuring 10 mm or less in diameter. A large proportion of these tumours are found coincidentally in the treatment of symptomatic goitre and most cases follow an indolent course with an excellent prognosis. However, a more aggressive behaviour with regional and distant metastases does occur. The aim of this study was to evaluate if the immunohistochemical markers cyclin D1 or galectin-3 might indicate the presence of metastatic disease in patients with PMC at the time of diagnosis. Material and methods. From the 1(st) of January 1996 to 31(st) of December 2002 a total of 169 PMC patients were diagnosed and registered in the national Danish thyroid cancer database DATHYRCA and 131 of these were eligible for the study. Forty-three (33%) had histologically verified regional or distant metastases. Slides were cut from the primary tumour and immunostaining and quantification was subsequently performed. Results. The percentage of positive cells was examined for patients with and without metastases. For cyclin D1 the median values were 31% (range: 0-59) and 21% (range: 0-75), respectively, showing a statistically significant difference (p=0.02). For galectin-3 the medians were 87% (range: 6-96) and 85% (range: 0-99) and no significant difference was found. Conclusion. Cyclin D1 showed significantly higher median expression in patients with metastases compared to those without, indicating a correlation to tumour aggressiveness. However, both groups showed large variation in expression, which disqualify the marker as a discriminator for the detection of metastases. Galectin-3 was without any significant correlation to the presence of metastases from PMC Udgivelsesdato: 2007-Sep-28

A case of a massive cholesteatoma of the frontal sinus in an 80-year-old female is reported. This lesion is very uncommon and a review of the English literature revealed only 12 reported cases. Characteristically, these tumors present unilaterally as a painless, slow-growing mass, often accompanied by frontal headache, proptosis and diplopia, and without a history of frontal sinus infection. Curative treatment includes total excision of the cholesteatoma with adequate drainage, which leaves the patient with an excellent prognosis although late recurrence has been reported. While this type of lesion is very rare, it is nevertheless an important differential diagnosis of frontal sinus tumors, due to the associated destruction of bone.

To determine the rates of and risk factors for postoperative complications following total laryngectomy in patients treated with radiotherapy or chemoradiation.Retrospective longitudinal study.Tertiary medical centres.A total of 143 patients undergoing total laryngectomy for squamous cell carcinoma of the larynx or hypopharynx.Overall postoperative complications and fistula formation.Overall postoperative complications, fistula formation, wound infection, bleeding and wound necrosis within one year after total laryngectomy occurred in 56.6%, 42.3%, 31.0%, 11.3% and 9.2% of patients, respectively. Stenosis of the pharynx/oesophagus and stoma shrinkage within five years after surgery were each seen in 18.2% of cases. In 66.7% of cases, conservative treatment of the fistulas was chosen. Rehospitalisations within five years occurred for 44.8% with a median rate of 1.5 (range 1-11). Smoking status (P = 0.005 and 0.013) and chronic obstructive pulmonary disease (COPD) (P = 0.013 and 0.011) were significant risk factors for both overall postoperative complications and fistula formation in uni- and multivariate analysis. Tumour localisation in the hypopharynx was associated with overall postoperative complications (P = 0.036). Residual tumour or cancer recurrence was associated with late-onset fistulas (P0.001).The frequencies of postoperative complications after total laryngectomy were comparable with similar international studies, although fistula formation rate is increasing in Denmark. We suggest optimising treatment of COPD and to further encourage to smoking cessation. We propose that development of fistulas2 months after surgery prompts immediate biopsies. Additionally, we suggest standardised registration of surgical techniques to identify variables affecting the frequency of postoperative complications.

Objectives No previous prospective study has evaluated harmonic scalpel in thyroidectomy for substernal goiter. The objective of this study was to evaluate the use of harmonic scalpel (FOCUS shear, Ethicon Endo-Surgery) in thyroidectomy for substernal goiter for blood loss, operative time, hospital stay and complications. Materials and methods Prospective non-randomised study of 242 consecutive patients with substernal goiter out of 2258 patients (11%) who underwent thyroidectomy. A total of 121 patients had thyroidectomy performed with bipolar electrocoagulation and knot-tying techniques and 121 patients had harmonic scalpel thyroidectomy. Results The use of harmonic scalpel was associated with significant reduction in intraoperative blood loss (50 vs. 100 mL, p = 0.001), postoperative haemorrhage (4% vs. 12%, p = 0.03) and length of hospital stay (2 vs. 3 days, p = 0.001). The mean operative time was significantly longer in the harmonic group. Conclusion Harmonic scalpel is a safe tool for thyroidectomy for substernal goiter. Its utilisation is associated with reduced blood loss, lower incidence of postoperative haemorrhage and shorter hospital stay.

The pathogenesis of otitis media is a multifaceted process that is not completely understood. Eustachian tube dysfunction plays a central but uncertain role, as do viral and bacterial microorganisms. Of the latter, the three most important are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. This article reviews the various mechanisms of infection and the immune system's response to them.

Moraxella (Branhaomella) catarrhalis is frequently present in the nasopharyngeal microflora of small children, especially during episodes of acute otitis media . By means of ribotyping (restriction endonuclease analysis of chromosomal DNA combined with rRNA probing), we studied the genetic heterogeneity of 78 cultures of M. catarrhalis obtained from different localities in the nasopharynx of nine young children with secretory otitis media. Using HindIII and PstI as endonucleases, five different ribotypes were recognized, representing at least five different genotypes of M. catarrhalis. The distribution of these types was found to be almost identical to the distribution among 16 M. catarrhalis strains cultured from middle ear exudates of 16 children with acute otitis media. Ribotype HAPA was found in two-thirds of all the cultures investigated, and 44% of the children harboured more than one ribotype in the nasopharynx at the same time. The vast majority of the nasopharyngeal M. catarrhalis cultures were beta-lactamase positive. One child had both a HAPA ribotype, beta-lactamase-negative strain in the nasopharyngeal secretions, and HAPA ribotype, beta-lactamase-positive strains at the entrance of the eustachian tube, the nasopharyngeal tonsils, the folds of the nasopharyngeal tonsils and the oropharynx. All except one of the M. catarrhalis strains cultured from middle ear exudates were beta-lactamase positive.

The human palatine tonsils, which belong to the central antigen handling sites of the mucosal immune system, are frequently affected by acute and recurrent infections. This study compared the microbiota of the tonsillar crypts in children and adults affected by recurrent tonsillitis with that of healthy adults and children with tonsillar hyperplasia. An in-depth 16S rRNA gene based pyrosequencing approach combined with a novel strategy that included phylogenetic analysis and detection of species-specific sequence signatures enabled identification of the major part of the microbiota to species level. A complex microbiota consisting of between 42 and 110 taxa was demonstrated in both children and adults. This included a core microbiome of 12 abundant genera found in all samples regardless of age and health status. Yet, Haemophilus influenzae, Neisseria species, and Streptococcus pneumoniae were almost exclusively detected in children. In contrast, Streptococcus pseudopneumoniae was present in all samples. Obligate anaerobes like Porphyromonas, Prevotella, and Fusobacterium were abundantly present in children, but the species diversity of Porphyromonas and Prevotella was larger in adults and included species that are considered putative pathogens in periodontal diseases, i.e. Porphyromonas gingivalis, Porphyromonas endodontalis, and Tannerella forsythia. Unifrac analysis showed that recurrent tonsillitis is associated with a shift in the microbiota of the tonsillar crypts. Fusobacterium necrophorum, Streptococcus intermedius and Prevotella melaninogenica/histicola were associated with recurrent tonsillitis in adults, whereas species traditionally associated with acute tonsillitis like pyogenic streptococci and Staphylococcus aureus were scarce. The findings suggest that recurrent tonsillitis is a polymicrobial infection in which interactions within consortia of taxa play an etiologic role. The study contributes to the human microbiome data, to the understanding of the etiology of infections affecting the tonsils, and forms a basis for further insight into the consequences of the intense microbe-host interactions that take place in the tonsils.

Nodular toxic and non-toxic goitres are seen in approximately 15% of Danish women, and the pros and cons of thyroidectomy versus radioiodine (RI) therapy are often discussed. The purpose of this study was to evaluate the type and number of patients treated on the indication of hyperthyroidism or benign goitre who did not achieve a sufficient effect of RI therapy and therefore needed thyroidectomy.Between 1 January 2003 and 1 January 2008, a total of 873 patients were treated with RI on the indication of benign thyroid disease at Herlev Hospital (Denmark). Data concerning these patients were listed consecutively in a database. The data were subsequently cross-checked with the Danish Thyroid Surgery Quality Register (THYKIR) which contains data on all patients treated with thyroid surgery at Danish departments of ear, nose and throat and head and neck surgery since 1 January 2001. Patient data were also cross-checked with the National Patient Register data. The unique Danish social security numbers were used to compare data.Among the 873 patients treated with RI, 36 were listed in the THYKIR database. Eleven of these had primary thyroid surgery and subsequently underwent RI treatment due to goitre recurrence. Twenty-five patients first received RI therapy and subsequently thyroidectomy due to persisting symptoms (17 had non-toxic goitre and compression symptoms (among these eight had a large goitre with a thyroid volume of100 ml (range 100-389 ml)), five had nodular toxic goitre and three had diffuse toxic goitre and continuing hyperthyroidism despite RI treatment. Thyroid surgery revealed a small (2-3 mm) cancer in two patients, both from the group of patients with nodular toxic goitre.The effect of RI therapy sufficiently solved the problem (hyperthyroidism or goitre) and surgery was hence avoided in 848 of 873 (97%) patients. However, within the group of patients with nontoxic goitre, a subgroup of patients with large goitres seems to be resistant to RI treatment and does not achieve sufficient effect under the current RI therapy regime.not relevant.Danish Data Protection Agency (Datatilsynet) HEH.afd.O.750.86-7 and 2010-231-0068.

To describe outcome and prognostic factors in a national Danish series of patients treated for salivary gland carcinoma. From three Danish nation-wide registries and supplementary patient records, 871 patients diagnosed with primary major or minor salivary gland carcinoma in the period from 1990 to 2005 were identified. A total of 796 (91%) histological specimens were revised according to the WHO 2005 classification. The median follow-up time was 78 months. Three hundred and thirty-four patients (38%) experienced recurrence. Crude survival, disease-specific survival and recurrence-free survival after 5 and 10 years were 66%, 76%, 64% and 51%, 69%, 58%, respectively. In multivariate analysis age, latency, stage, microscopic margins, vascular invasion and histological grade were all independent prognostic factors with regards to crude and disease-specific survival. Stage, microscopic margins, vascular invasion and histological grade were independent prognostic factors for recurrence-free survival. Age over 61 years, latency under 8 months, stage 3+4 disease, involved or close microscopic margins, vascular invasion and high histological grade are all independent prognostic factors with a negative impact on survival in salivary gland carcinoma patients. This knowledge can be helpful in guiding clinicians in daily work and choice of treatment across the large variety of salivary gland carcinoma subtypes.

The immediate and permanent frequency of injury to the marginal mandibular branch of the facial nerve (MMN) after neck dissection has only scarcely been addressed in the medical literature. We investigated the risk of injury in 159 consecutive patients after neck dissection for various reasons in level I B and level II A, respectively. In 95 patients with oral cancer 13 (14%) of the cases had malfunction of the lower lip domain 2 weeks after neck dissection in level I B indicating paresis to the MMN. Follow-up analyses 1-2 years after the operation showed permanent paralysis in 4 to 7% of the cases in whom two of them had the nerve sacrificed for oncologic reasons during the operation. In 18 patients with parotic cancer the corresponding permanent frequency of MMN paralysis was 11.1%. In 46 patients with neck dissection in level II A but not in level I B, no paresis of the MMN was registered. Recognition of the MMN during the operation, pre- or postoperative radiation therapy, re-operation for deep hemorrhage, age, gender or postoperative infection did not have any statistically significant influence on the frequency of MMN injury. In conclusion we found a moderate risk of injury to the MMN after neck dissection in level I B whereas the corresponding risk after level II A dissection was negligible.

To describe the incidence, site and histology (WHO 2005) of salivary gland carcinomas in Denmark. Nine hundred and eighty-three patients diagnosed from 1990 to 2005 were identified from three nation-wide registries. The associated clinical data were retrospectively retrieved from patient medical records. Histological revision was performed in 886 cases (90%). Based on histological revision, 31 patients (3%) were excluded from the study leaving 952 for epidemiological analysis. The mean crude incidence in Denmark was 1.1/100,000/year. The male vs. female ratio was 0.97 and the median age was 62 years. The parotid gland was the most common site (52.5%) followed by the minor salivary glands of the oral cavity (26.3%). The most frequent histological subtypes were adenoid cystic carcinoma (25.2%), mucoepidermoid carcinoma (16.9%), adenocarcinoma NOS (12.2%) and acinic cell carcinoma (10.2%). The revision process changed the histological diagnosis in 121 out of 886 cases (14%). The incidence of salivary gland carcinoma in Denmark is higher than previously reported. More than half of salivary gland carcinomas are located in the parotid gland with adenoid cystic carcinoma being the most frequent subtype. Histological classification of salivary gland carcinomas is difficult and evaluation by dedicated pathology specialists might be essential for optimal diagnosis and treatment.

The traditional surgical approach for primary hyperparathyroidism (PHPT) involves a bilateral neck exploration to identify all parathyroid glands and remove the suspected pathological parathyroid gland(s). However, with improved preoperative imaging modalities and the use of perioperative measuring of PTH the unilateral minimal invasive approach has been introduced. The purpose of this study was to describe the results of minimal invasive parathyroidectomy.A total of 116 consecutive patients underwent PHPT surgery (117 procedures) with a minimal invasive approach.A true positive sestamibi scintigraphy was found in 75 of 116 (65%) cases. A total of 80 patients (69%) underwent a unilateral surgical procedure and 56 patients (48%) minimally invasive surgery. In 113 of 117 procedures one or more pathological parathyroid glands were found. The median duration of the surgical procedure was 55 minutes and only 35 minutes for the minimal invasive approach. No permanent vocal cord paralysis was found. In two patients, persistent mild hypercalcaemia was encountered postoperatively and in a further patient recurrence was seen one year after.In our hands the success rate for focused minimal invasive surgery for the treatment of PHPT is equal to or better than results obtained by the traditional bilateral neck exploration. The minimally invasive approach is a less time-consuming and safe procedure with a low complication rate. Postoperative hypocalcaemia is rare and further advantages include improved cosmetic results and reduced surgical trauma.

Udgivelsesdato: 2009-Mar-20 As bleeding in the neck region is a potentially life-threatening complication, we found it imperative to concretize the frequency and to identify possible reasons for this complication. A national database of all thyroid surgery performed inside the specialty of ENT Head and Neck Surgery (THYKIR) was established in January 2001. This nationwide cohort study represents 5,490 patients included until December 2007. Overall hemorrhage frequency was 4.2% with a wide variation among departments. Multiple regression analysis identified age, male gender, malignant histology and extent of surgery as independent risk factors for hemorrhage. Increased hospital stay and infection rates were found in patients treated with drainage. The median time for onset of postoperative hemorrhage was 3 h (range 0-105). Compared with international literature our incidence of post-thyroidectomy hemorrhage is relatively high. Improvement might be reached by the exchange of experience between departments with focus on adequate surgical technique and careful hemostasis.

The treatment strategy for oral squamous cell carcinoma in Denmark has traditionally varied between the different head and neck oncology centres. A study group within the Danish Society for Head and Neck Oncology (DSHHO) was formed with the aim of optimising and standardising the treatment strategy. The approach was to use single modality treatment for stage I, stage II and some stage III and combined modality treatment for stage III and IV. Surgery was the preferred treatment when it was considered possible to perform a radical excision of the tumour and possible lymph node metastases with acceptable aesthetic and functional outcome. The implementation of a recognised national guideline facilitates prospective studies on a large well-characterised cohort. This increases the possibility of obtaining valid data on parameters such as morbidity, loco-regional control and survival. In addition the establishment of a reference program facilitates national monitoring of the treatment using defined indicators and standards.

The keratin composition of stratified squamous epithelia has a complex pattern, which varies in different regions and as a result of pathological developments. The exact factors responsible for the characteristic keratin composition in a given epithelium are unknown. However, the environment, including factors from the connective tissue, is known to influence epithelial morphology and keratin composition. We here report that the reticulated squamous epithelium of the crypts of palatine tonsils shows an extensive staining for keratins 5 and 19 in basal as well as suprabasal cells, in contrast to neighbouring non-reticulated crypt epithelium and the epithelium at the tonsillar surface, in which staining is restricted to basal cells. The reticulation of the crypt epithelium is thought to be initiated by infiltration of immune-related cells in a preexistent non-reticulated epithelium. The extensive staining for keratins 5 and 19 in reticulated crypt epithelium correlates with the presence of numerous immune system-related cells and marked expression of intercellular adhesion molecule-1 (ICAM-1), thought to be involved in inflammatory and immunological responses. The results suggest that the massive lymphocytic traffic in the reticulated crypt epithelium and the overall distinct immune environment are responsible for the unique keratin staining pattern observed.

• In 222 nonselected, otherwise healthy children, seven repetitive tympanometric screenings were performed from ages 4 to 7 years. At the last three screenings, otomicroscopy was performed and the changes of the eardrum were analyzed. At age five years 24%, at age six years 37%, and at age seven years 39% of all 444 ears had changes of the eardrum, either attic retractions of varying degrees, atrophy, and/or tympanosclerosis of the pars tensa. There was a notable correlation between eardrum abnormality, the tympanometric profile, and the frequency of acute otitis media. Some unstability of the eardrum abnormality occurred over the years, especially of attic retractions and tympanosclerosis. Treatment, especially by grommets, probably cannot prevent ear-drum abnormality. (Arch Otolaryngol1984;110:281-289)

• Five repetitive tympanometric screenings performed during one year in 288 randomized, otherwise healthy 4-year-old children showed that 50% of ears changed tympanogram type between each trial. The total frequency of secretory otitis was high; thus, 32% of all 576 ears had type B at least once and 73% had either type B or C 2 , indicating a middle ear pressure of −200 mm H 2 O or lower. At three trials during at least six months, 8% had type B and 24% either type B or C 2 . spontaneous improvement of secretory otitis was high, and type B improved in 78% to 88% of ears, although in some ears the type again deteriorated. Severe changes of the tympanic membrane were found in 0.5% of ears, and it is therefore advised to postpone surgical treatment of secretory otitis for three to six months. ( Arch Otolaryngol 1982;108:4-10)

Immunoglobulin A forms the specific immune barrier of mucosal surfaces against microorganisms and potential allergens. Immunochemical studies of nasopharyngeal secretions (NPS) from 97 children showed enzymatic degradation of IgA in 18.6% of the samples. The observed fragments are characteristically released from IgA by the activity of specific IgA 1 proteases produced by certain bacterial species. A significantly higher prevalence (P less than 0.001) of IgA cleavage was observed in NPS from children with atopic diseases (61.5%) than in controls (11.9%). These results indicate that bacterium-induced local defects in the mucosal immune barrier of the upper respiratory tract may be a factor in the pathogenesis of some forms of atopic disease.