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Background Frey syndrome is a common complication after parotidectomy. This study aimed to investigate the potential predictors for developing severe Frey syndrome after parotidectomy and to identify patients who may benefit from additional preventive maneuvers. Methods A total of 485 patients received parotidectomy because of parotid tumors at the Otolaryngology Department of the National Cheng Kung University Hospital, from July 2009 to November 2015. Only 115 of 485 patients were included in this study and to fill in a questionnaire to determine the occurrence and severity of Frey syndrome. Results A total of 115 parotidectomies were identified. 84 (73%, 84/115) patients were aware of the discomfort and were thus considered symptomatic. 39 (34%, 39/115) patients considered the symptoms apparently affected their quality of life. MSI tests showed that 56 (49%, 56/115) patients had a positive MSI test. By combining the results from symptom questionnaire and MSI test, 23 patients (20%, 23/115) had a severe form of Frey syndrome. Among all clinicopathological variables, the resected specimen size was the only significant predictor of the severe Frey syndrome group (P = 0.04). Disease pathology, tumor size, and adjuvant radiotherapy did not correlate with the severe Frey syndrome. Using receiver operating curve analysis, the best cutoff value of the resected specimen size (in largest dimension) for predicting severe Frey syndrome was 40 mm(sensitivity: 71.7%, specificity: 42.0%; area under the curve = 0.6483). The odds ratio of severe Frey syndrome with every 10 mm increase in the largest diameter of resected specimen was 1.30 (95% confidence interval, 1.01-1.68; P = 0.04). Conclusions Resected specimen size is the only significant predictor of developing severe Frey syndrome after parotidectomy. Preventive interventions may have to be considered in high-risk patients whose resected specimen size (in largest dimension) is greater than 40 mm.

Although Sistrunk operation is the standard method to treat thyroglossal duct cyst, the reported recurrence rates after a "classic" or "modified" Sistrunk procedure still varied from 0 to 15.8 %, indicating the existence of some technical uncertainties. While simple cystectomy has been recognized as the most important prognostic factor predicting thyroglossal duct cyst recurrence, whether other clinico-pathological parameters also affect disease recurrence has not been well studied. We retrospectively reviewed the medical records of all patients who underwent thyroglossal duct cyst surgery between June 1998 and June 2014 at our institution. Among the 180 primary patients, 160 patients received a "conservative" Sistrunk operation, while the remaining 20 patients received simple cystectomy only. Five patients (2.8 %, 5/180) had recurrence. Four of them received simple cystectomy while 1 had "conservative" Sistrunk operation. In univariable analysis, age (p = 0.02), history of previous infection (p = 0.004) and the type of resection (p = 0.001) were significantly correlated with disease recurrence. In multivariable analysis, the type of resection turned out to be the most important factor (p = 0.03) related to recurrence. In the most parsimonious model selected by backward elimination, both history of infection (p = 0.048) and the type of resection (p = 0.02) were important predictors of postoperative recurrence. Our results demonstrated that a "conservative" Sistrunk approach could provide a comparably low recurrence rate (0.6 %, 1/160) in dealing with primary thyroglossal dust cysts. Routine dissection of suprahyoid tissue may not be imperative. Overall, the type of resection and history of infection are the most important predictors of recurrence for thyroglossal duct cyst.

In the present study, the authors compared the long-term risk of nasopharyngeal carcinoma (NPC) of male participants in an NPC multiplex family cohort with that of controls in a community cohort in Taiwan after adjustment for anti-Epstein-Barr virus (EBV) seromarkers and cigarette smoking. A total of 43 incident NPC cases were identified from the 1,019 males in the NPC multiplex family cohort and the 9,622 males in the community cohort, for a total of 8,061 person-years and 185,587 person-years, respectively. The adjusted hazard ratio was 6.8 (95% confidence interval (CI): 2.3, 20.1) for the multiplex family cohort compared with the community cohort. In the evaluation of anti-EBV viral capsid antigen immunoglobulin A and anti-EBV deoxyribonuclease, the adjusted hazard ratios were 2.8 (95% CI: 1.3, 6.0) and 15.1 (95% CI: 4.2, 54.1) for those positive for 1 EBV seromarker and positive for both seromarkers, respectively, compared with those negative for both EBV seromarkers. The adjusted hazard ratio was 31.0 (95% CI: 9.7, 98.7) for participants who reported a family history of NPC and who were anti-EBV-seropositive compared with individuals without such a history who were anti-EBV-seronegative. The findings suggest that both family history of NPC and anti-EBV seropositivity are important determinants of subsequent NPC risk and that the effect of family history on NPC risk cannot be fully explained by mediation through EBV serologic responses.

Chronic suppurative otitis media, averaging 20 or more years of duration, has been associated with cancer in this region in 40%-80% of cases. Although human papillomaviruses (HPV) have been implicated in many human squamous-cell neoplasms, their role in the pathogenesis of middle-ear malignancies remains unexplored. In this study, we investigated the presence and subtypes of HPV in middle-ear carcinomas. Formalin-fixed and paraffin-embedded tumor tissues were sampled for DNA extraction. PCR was done with consensus primers, capable of detecting HPV 16, 18, 31, 33, 52b and 58. Typing of the products generated by consensus primers was performed with restriction enzyme digestion. It was found that a resulting 89% (8/9) of the middle-ear carcinomas contained HPV DNA. Coexistence of HPV 16 and 18 was detected in 3 squamous-cell carcinomas. HPV 16 was detected in 4 squamous-cell carcinomas and 1 adenocarcinoma. The high prevalence of high-risk-type HPV in carcinomas of the middle ear suggests that viral infection may be an important etiologic component in the carcinogenic process.

Juvenile nasopharyngeal angiofibroma (JNA) is a benign but aggressively expansile lesion that occurs exclusively in prepubescent or pubescent males. Its incidence is approximately 0.05% to 0.5% of head and neck tumors,112 so every otolaryngologist will have the occasion to encounter this highly vascular tumor. Of note is its serious complication of massive bleeding, which may occur preoperatively or perioperatively. Although radiation therapy, hormone therapy, cryotherapy, electrocoagulation, sclerosis, and chemotherapy have been tried with variable success, transarterial embolization (TAE) followed by surgical excision has become the most frequent method of treatment. The typical JNA approaches without intracranial invasion include lateral rhinotomy, transpalatal, sublabial degloving, tramszygomatic, or a combination of these technical approaches.3 With the advent of superior diagnostic imaging modalities, therapeutic embolization, and the prevalent use of the endoscope, new approaches can be used. This article reports a new experience in managing a case of JNA via a transnasal endoscopic approach.

Purpose: Acquaintance with the severity of inflammatory condition and mucociliary destruction of the protympanic eustachian tube (ET) mucosa may provide some insight for management during surgery for cholesteatoma. Materials and Methods: Protympanic eustachian mucosa was obtained from 25 patients undergoing ear surgery for cholesteatoma and from 5 cadavers undergoing dissection for a gross anatomy course. The specimens were processed for both scanning electron microscopy (SEM) and transmission electron microscopy (TEM). Results: According to SEM, decreased ciliated cells were noted. Residual ciliated cells and numerous white blood cells (WBC) were noted in the protympanic mucosa of the eustachian orifice. Bacilli were commonly noted at the mucosal surface. Cilia might be collapsed and stagnated with mucus secretion. This finding was consistent with those of the TEM: that cilia of varied directions were embedded in mucus. Mucociliary function was impaired under such conditions. The mucosal alteration was severe in some children; there was no ciliated cell visible. According to the TEM, the mucosal cells contained numerous secretory granules and mitochondria. Polymorphous nuclear cells were noted in the submucosal area that was edematous. Compound cilia were rather common. Mucus blanket covered mucosal cells with widening intercellular spaces. In addition, neither cilia nor microvilli were visible in severe mucosal alteration. Conclusions: These occurrences indicated the presence of inflammatory reaction and impairment of clearance function of eustachian mucosa in cholesteatomatous ears. Thorough irrigation during surgery and antimicrobial therapy after surgery are warranted.

A case report of orofacial pain originating from both dental and nondental conditions is presented. The spontaneous throbbing pain initiated from the left maxillary second premolar and spread throughout the entire upper part of the face to the frontoparietal area. Root canal treatment of the maxillary second premolar did not resolve the chief complaint. Magnetic resonance imaging examination revealed hypertrophy of the left inferior turbinate and soft tissue haziness in the left maxillary sinus floor. After antrostomy, submucosal turbinectomy, and endodontic treatment, the patient was free from pain. The final diagnosis of this case, in addition to pulpitis, was maxillary sinusitis with chronic rhinitis. The multiple factors associated with the etiology made the diagnosis difficult. The mechanism of referred pain from the maxillary sinus and paranasal mucosa to the maxillary teeth and face is discussed.

Since radiotherapy is the treatment of choice for nasopharyngeal carcinoma, the influence of irradiation on the temporal bone is of great concern for these patients. In this study, the caloric test and posturography were used to investigate vestibular function in 41 irradiated patients with nasopharyngeal carcinoma. Caloric testing showed a high incidence of canal paresis; five unilateral and 10 bilateral. Factors such as middle ear effusion had no significant effect on the occurrence of canal paresis. Posturography showed no difference from the control group. The authors conclude that the influence of irradiation on the vestibular apparatus of patients with nasopharyngeal carcinoma might result in a canal paresis, while postural control is preserved. Central compensation may play an important role in the postural control of these patients.

During 1978 and 1979, an episode of poisoning from ingestion of rice oil contaminated with polychlorinated biphenyls and polychlorinated dibenzofurans occurred in central Taiwan. We followed-up children who had been born between June 1978 and March 1985, as well as matched unexposed children. The mothers of exposed children had consumed contaminated oils before the children were born. In 1993, otolaryngologists examined the middle ear of each child with a pneumatic otoscope, and they measured the middle-ear pressure by tympanometry with a Rion RS20 impedance audiometer. The exposed children had a significantly higher prevalence of middle-ear diseases than their matched controls. The exposed children who had ear diseases had higher serum levels of 2,3,4,7,8-pentachloro- and 1,2,3,4,7,8-hexachloro-dibenzofurans than the children who did not have similar diseases. Therefore, in this study, children exposed to polychlorinated biphenyls and polychlorinated dibenzofurans had a higher incidence of middle-ear diseases than their controls.

Mucosa of the middle ear was obtained from the promontory wall in each of 20 patients during cholesteatoma surgery. Specimens were processed for both scanning and transmission electron microscopy. Non-ciliated mucosal cells were commonly found, with most being secretory cells with secretory droplets and microvilli. The patterns of distribution of microvilli on the surface of these cells were variable. The interciliary spaces were stagnated with secretion. Bacilli were present in five cases. Falloff of mucosal cells was common and intercellular spaces were widened. Compound cilia were observed sporadically. Polymorphic nuclear inflammatory cells, macrophages and fibroblasts appeared in the submucosal area. These findings indicate that although remaining adjacent mucosa after removal of cholesteatoma looks free of disease under the operating microscope, it is actually in a diseased condition with impaired mucociliary function. The cells and bacteria seen microscopically may account for postoperative inflammation, thus warranting continued postoperative antimicrobial medication.

Adult Sprague-Dawley rats (n = 64) were used in this study to replicate in an animal model tissue change formed clinically during radiotherapy for the treatment of head and neck malignancy. Gamma irradiation was administered to both ears of each rat, using a cobalt-60 machine. A total dose of 30 Gy was administered, with 500 cGy/fraction given on 6 consecutive days to a time-dose fractionation value of 81. Animals were then sacrificed at sequential intervals. The tympanic bullae were removed and the mucosa was processed for scanning electron microscopy. Tissue findings indicated that irradiation might initially have no influence on the clearance activity of the middle ear. However, ultrastructural changes showed stagnation of secretion between cilia, falling off and different directions of the cilia, fused or collapsed cilia, and eustachian tube dysfunction (with mucosal edema). These findings possibly account for the occurrence of middle ear effusions in patients during and after radiotherapy for head and neck malignancy. It is our concept that insertion of a ventilation tube is necessary if abnormal mucociliary function appears, in order to clear and prevent the accumulation of any middle ear effusions and prevent further mucociliary dysfunction.

Langerhans cells have been found in cholesteatomas for many years. It is believed that they are immunocompetent cells and have the same role in cell-mediated immunologic mechanisms in cholesteatoma as well as in skin. This study used the transmission electron microscope to observe the cellular characteristics of Langerhans cells and the apposition phenomenon of Langerhans cells with lymphocyte-like cells in human middle ear cholesteatomatous tissue. These findings are evidence for cell-mediated immune responses in middle ear cholesteatomas. In vitro Langerhans cells conditioned medium prepared from Lewis rat skin was used to show its effects on protein synthesis and the differentiation of basal cells. Since the cellular behaviour of basal cells is important in the development and pathogenesis of cholesteatoma, the present study shows that Langerhans cells may have some role in the clinical formation of a cholesteatoma. Since cells extracted from rat skin may have a different response from that of cells from human middle ear cholesteatoma, further investigations are necessary to compare the biological effects of both tissues.

An indirect immunofluorescent method with monoclonal anti-cytokeratin antibodies was used to localize various cytokeratins in human middle ear cholesteatoma. The 50 K/58 K and 56.5 K/65-67 K paired cytokeratins are markers of skin type and were found in the specimens of human middle ear cholesteatomas studied. In contrast, the 40 K and 45 K cytokeratins (markers of simple epithelia), the 48 K cytokeratin (marker of hyperproliferative epidermal disease) and the 51 K cytokeratin (marker of internal organ epithelia) were absent in human middle ear cholesteatoma. These findings indicate that the pattern of cytokeratins in human middle ear cholesteatoma is similar to that of skin but is different from those of simple epithelium, internal organ epithelia, and hyperproliferative epidermal disease. These findings also support the skin type epithelial origin of cholesteatoma and strongly favor the migration theory in the genesis of cholesteatomas.

Filaggrin, a histidine-rich protein, was located immunohistochemically in human middle ear cholesteatoma by specific antibody. It was found to be localized in the cytoplasm of the granular layer cells and cornified layer. The pattern of distribution is similar to that of epidermis. Filaggrin is a major component of keratohyalin which is a distinct component of the differentiating epidermal cells. Thus the presence of filaggrin in cholesteatoma suggests epidermal characteristics of the cholesteatoma.

The accumulation of desquamated keratinizing squamous epithelial cells appears to be a crucial factor in the pathogenesis of middle ear cholesteatomas. The accumulation of keratin debris is due to the proliferation and the terminal differentiation of basal keratinocytes. Since cholesteatomas are usually associated with inflammatory reactions in the middle ear cavity, we examined the effects of a granulation tissue conditioned medium on the terminal differentiation of basal keratinocytes in vitro. This conditioned medium stimulated the terminal differentiation of basal keratinocytes by showing: (a) increased incorporation of 3H-leucine into cell envelopes; (b) an increased number of SDS-insoluble cell envelopes; and (c) increased transglutaminase activity (as a marker for terminal cellular differentiation). Our present studies further suggest that inflammatory granulation tissue plays an important role in the clinical growth and development of the cholesteatoma.

Fibronectin was localized in human cholesteatoma tissues by immunohistochemical methods. The avidin-biotin-peroxidase complex staining method was used with specific fibronectin antibody. Fibronectin appeared to be localized in the matrix of the cholesteatoma studied, particularly on the surface of the cell membranes and the nuclei of the basal cells and in connective tissue. Fibronectin was not seen in the granular layer or in the keratin area. Fibronectin was found on the surface of granulation tissue, mononuclear cells, fibroblasts and endothelial cells of blood vessels. These findings were confirmed by the immunofluorescent staining method. Our previous study showed that fibronectin induced a migration of keratinocytes, macrophages and fibroblasts demonstrated by the Boyden's chamber chemotaxis assay. Macrophages and fibroblasts were shown to produce collagenase, a bone resorption factor, in cholesteatomatous tissue. The present study showed the presence of fibronectin in the matrix of cholesteatoma and granulation tissue, suggesting that fibronectin might play an important role in the clinical development and invasive behavior of cholesteatoma.