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Bisphosphonate Induced Mandible Bone Osteonecrosis in A Patient with Prostate Cancer
ORAL AND MAXILLOFACIAL PATHOLOGY e188 Abstracts Department of Oral and Maxillofacial Pathology, Ragas dental college, Chennai Objective: Alteration of taste leads to change in dietary habits with systemic consequences. Tobacco and alcohol users are known to have altered taste sensations (TS). Here we ascertain the pattern of altered TS in tobacco and alcohol users in our institution. Study Design: Four groups: group A (no habits, n¼25), group B (smokers and alcohol users, n¼25), group C (smokers, alcohol and tobacco chewers, n¼25) and group D (alcohol users with tobacco chewing, n¼25). Taste strips for sweet, salt, sour and bitter at four concentrations were used to ascertain the taste threshold as and high (1) to low(4). Data collected was analyzed by chi-square test in SPSS v.16.0. Results: Between groups A,B,C and D the threshold levels for sweet, salt were not altered while the threshold level for sour(p¼0.02) and bitter(p¼0.005) was significantly increased. Conclusions: Our study shows that tobacco and alcohol adversely affects the sour and bitter threshold. Keywords: Taste sensation, Tobacco, Alcohol, Threshold level
WILSON’S DISEASE: IS PULP AFFECTED? Taha Emre Köse1, Onur Dincer Köse2, Hülya Cakır Karabas1, Merva Soluk Tekkes¸in3, 1Department of Dentomaxillofacial Radiology, Istanbul University, Istanbul, Turkey; 2Department of Oral and Maxillofacial Surgery, Istanbul University, Istanbul, Turkey; 3Department of Tumour Pathology, Instıtute of Oncology, Istanbul University, Istanbul, Turkey Wilson’s disease (WD) is an autosomal recessive disorder which was first described as hepatocellular degeneration by Kinnier Wilson in 1912. WD is caused by mutation in ATP7B gene. Defective biliary excretion of copper causes the accumulation of copper in the organs, including liver, brain, kidney, and cornea. This accumulation leads to organ damage. A 28 year-oldmale patient, diagnosed as WD 12 years ago, was referred to our clinic for periodontal complaints. After clinical examination, two molar teeth were extracted and sent to the pathology department for microscopic evaluation. The teeth were decalcified in 10% formic acid solution for two weeks. The decalcified specimens were embedded in paraffin and cut into 5 mm thick sections on charged slides. The sections were stained with orcein to detect possible accumulation of copper. In this case report, we research if there are any particular accumulation and/or degenerative changes in pulp, enamel and dentin. Keywords: Wilson’s disease, pulp, copper accumulation
ODONTOGENICTUMOURS: A MULTICENTRIC RETROSPECTIVE STUDY OF 2000 CASES IN TURKISH POPULATION S. Elif Gültekin1, Burcu Sengüven1, Emre Barıs¸1, Özlem Özer Yücel1, Merva Soluk Tekkes¸in2, Ömer Günhan3, Aysun Uguz4, Demet Etit5, 1Department of Oral Pathology, Faculty of Dentistry, Gazi University, Ankara, Turkey; 2Department of Tumour Pathology, Institute of Oncology, Istanbul University; 3Department of Pathology, Gülhane Military Medical Academy, Ankara, Turkey; 4 Department of Pathology, Faculty of Medicine, Çukurova University, Adana, Turkey; 5Department of Pathology, Fac_ ulty of Medicine, Izmir KatipÇelebi University, Turkey Objective: Data from different countries show significant differences in frequency of odontogenic tumors, which were
OOOO March 2015 derived from epithelial, ectomesenchymal and/or mesenchymal remnants of tooth-forming apparatus. Study Design: Current study describes the epidemiology and clinical presentation of odontogenic tumors from five pathology services from Turkey. The classification was made according to 2005 WHO histological classification. Results: A total of 2000 odontogenic tumor cases retrieved from the archival files between 2002 and 2012 were retrospectively analyzed for gender, age, tumor site and relative frequency of tumor types. Of these tumors only 0.37% was malignant. Keratocystic odontogenic tumor was the most frequent type (57.2%), followed by odontoma (16.7%), and ameloblastoma (15.08%). The mean age of the patients was 35.09and the malefemale ratio was 1: 0.92. Mandible posterior was the most frequent location. Conclusions: The present study confirms the frequency of keratocystic odontogenic tumor and ameloblastoma which are not rare in Turkish population. Keywords: epidemiology, odontogenic tumors
PERICORONAL RADIOLUCENCY ASSOCIATED WITH AN IMPACTED PREMOLAR TOOTH Ülkem Aydın1, Ufuk Ates¸2, Burcu Sengüven3, 1Department of Dentomaxillofacial Radiology, Baskent University, Ankara, Turkey; 2Department of Dentomaxillofacial Surgery, Baskent University, Ankara, Turkey; 3Department of Oral Pathology, Faculty of Dentistry, Gazi University, Ankara, Turkey Aplasia of the mandibular second premolar (MnP2), anomalous distal inclination of the contralateral MnP2 bud and delayed tooth formation is one of the dental anomaly patterns (DAP). In addition, the odontogenic tissue around the impacted tooth has the propensity to differentiate into a wide variety of pathological lesions. Detection of such pathologic lesions usually requires removal of the tooth and the lesion. A systemically healthy 16year-old female patient attended our clinic for follow-up of her impacted tooth. On the panoramic radiograph, a pericoronal radiolucency associated with the distoangularly oriented impacted right MnP2, and aplasia of its antimere was detected. The patient was then referred for surgical operation. Histopathologically, the diagnosis was hyperplastic dental follicle. The purpose of the present report was to present the radiographic and histopathologic features of a case of pericoronal radiolucency associated with an impacted MnP2 and to describe one of the DAP. Keywords: dental anomaly patterns, hyperplastic dental follicle
BISPHOSPHONATE INDUCED MANDIBLE BONE OSTEONECROSIS IN A PATIENT WITH PROSTATE CANCER Ahmet S¸alvarcı1, Serdar Altınay2, 1Novafertil, Department of Urology, Konya, Turkey; 2Ba gcılar Training and Research Hospital, Department of Pathology, Istanbul, Turkey In large series, the incidence of bisphosphonate-associated osteonecrosis is 65% in the lower jaw, 26% in the upper jaw and %9 in both jaws. Androgen-deprivation therapy and third-generation bisphosphonate zoledronic acid treatment was initiated to a 64-year-old patient with metastatic prostate cancer. During the 36th month of treatment the patient presented with swelling of the lower jaw and was diagnosed and treated for abscess. Pain persisted for three months despite the treatment. On physical examination, open wound of the oral mucosal was observed. Computer tomography showed a lesion consistent with bone
OOOO Volume 119, Number 3 necrosis in the lower jaw’s fovea sublingual region. The diagnosis of necrotic bone was made by observing areas characterized by empty osteocyte lacunae in pathological examination. Although it is suggested that oral hygiene education benefits in reducing the risk of bisphosphonate related osteonecrosis, still the risk of developing it is present. Keywords: Bisphosphonate, mandible, bone, osteonecrosis
BIPHASIC MALIGNANT TUMOR OF HYPOPHARYNX: SYNOVIAL SARCOMA? Serdar Altınay1, Salih Aydın2, Ümit Tas¸kın2, 1Bagcılar Training and Research Hospital, Department of Pathology, Istanbul, Turkey; 2Ba gcılar Training and Research Hospital, Department of Ear&Nose&Throat, Istanbul, Turkey Oropharyngeal synovial sarcoma is extremely rare. We present a 44 year old male patient with a lesion elongating through the hypopharynx. The patient was admitted with a 3-4 months history of hoarseness, difficulty of swallowing and pain in the right ear. Physical examination revealed a 3 3 cm mass in the left tonsil causing partial obstruction of the hypopharynx. Partial pharyngectomy and left functional neck dissection were performed. Neoplasms of biphasic morphology were found in the microscopic evaluation of the specimen. Tumor cells showed strong CK7, CK19 and EMA immunoreactivity and Bcl-2, CK5 / 6 and p53 focal staining. S100, CD99, CD31, CD34 staining were negative. Based on its features, this case was reported as a synovial sarcoma like biphasic malignant tumor. Synovial sarcoma should be considered in the differential diagnosis of oropharyngeal region tumors. Genetic analysis is recommended in order not to face a diagnostic dilemma. Keywords: Hypopharynx, synovial sarcoma, biphasic tumor
THYROID FOLLICULAR CARCINOMA METASTASIZED TO THE PARANASAL SINUS, LUNG AND BONE, SHOWING EXTENSIVE CLEAR CELL MORPHOLOGY Serdar Altınay1, Ümit Tas¸kın2, Salih Aydın2, Mehmet Faruk Oktay2, 1Bagcılar Training and Research Hospital, Department of Pathology, Istanbul, Turkey; 2Bagcılar Training and Research Hospital, Department of Ear&Nose&Throat, Istanbul, Turkey Follicular thyroid carcinoma metastasis to the paranasal sinuses is extremely rare. A 68-year-old female patient presented with a history of 2 months of swelling and loss of vision in her left eye. Brain MRI revealed a 68 39 53 mm irregularmargin soft tissue lesion with malign characteristics that showed intense homogenous contrast enhancement. It was mainly localized in the left nasal cavity extending into the left orbit and invading the clivus and sella. Biopsy showed tumor cells of extensive clear cell morphology adjacent to the nasal mucosa. In immunohistochemical studies, diffuse Pan CK staining cells did not show immunoreactivity with GFAP, CD10 and EMA. Immunohistochemistry for thyroid transcription factor-1 (TTF-1), thyroglobulin was markedly positive. The charecteristics of this case are consistent with follicular thyroid carcinoma metastasis. Beside morphologic and immunohistochemical findings, clinical findings are also important in differentiating clear cell tumors morphology. Keywords: Thyroid follicular carcinoma, metastasis, paranasal sinus, lung, bone, clear cell morphology.
ABSTRACTS Abstracts e189 SUSPECTED RECURRENCE IN PATIENT DIAGNOSED WITH SQUAMOUS CELL CARCINOMA OF THE MANDIBLE: ACTINOMYCES INFECTION Serdar Altınay1, S¸enay Yalçın1, Ahmet Cemal Aykıt2, 1Ba gcılar Training and Research Hospital, Department of Pathology, Istanbul, Turkey; 2Kemerburgaz University, Medical Faculty, Department of Aesthetic Plastic Surgery, Istanbul, Turkey Lower lip cancer constitutes 88-98% of the lip cancers. It is a common malignancy of the head and neck region seen mostly in 50 to 60 years old men. The relapse rate is 5% and the second primarily development is also 5% seen after treatment. A 60-yearold male patient presented with left mandible recurrence one year after being diagnosed with lower lip squamous cell carcinoma. Two years later, bone and soft tissue material of the same region were examined with the recurrence suspicion. All the material microscopic examination revealed. Evidence of primary and / or metastatic neoplasms was not observed. PAS stained Actinomyces infection was noticed between the trabecular of the bone tissue. In practicing oncologic pathology it is important not to focus only on the tumor but to keep in mind the possible presence of non-tumor lesion. Keywords: Recurrence, squamous cell carcinoma, mandible, actinomyces infection
HISTOPATHOLOGICAL DIVERSITY OF PAROTIDECTOMY MATERIALS IN TURKISH POPULATION: RETROSPECTIVE ANALYSIS OF 136 CASES Serdar Altınay1, Ümit Tas¸kın2, Salih Aydın2, Mehmet Sar3, 1 Ba gcılar Training and Research Hospital, Department of Pathology, Istanbul, Turkey; 2Ba gcılar Training and Research Hospital, Department of Ear & Nose & Throat, Istanbul, Turkey; 3Bakırköy DrSadi Konuk Training and Research Hospital, Department of Pathology, Istanbul, Turkey Objective: We have aimed to compare the demographic data in parotid tumors with the data in literature. Study Design: This study was conducted retrospectively on 136 parotidectomy materials operated in our clinic between May 2009-May 2013. Their age, gender, tumor diameter, histopathological diagnosis and surgical margin status were recorded. Results: The benign cases were 112 (82.4%), while the malignant cases were 24 (17.6%). Warthin tumor was more apparent in males (p<0.05). Pleomorphic Adenoma was detected most frequently among benign pathologies at 61.6% (69/112), while the Warthin Tumor was detected as the second. Mucoepidermoid Carcinoma and Carcinoma ex Pleomorphic Adenoma was detected at equal frequency at 20.8% (5/24) among malign tumors. While the surgical margin was positive in 10 patients among malign tumors (41.7%), all of the benign tumors were negative (p<0.01). Conclusions: Pleomorphic adenoma was the most frequently reported benign tumor almost in all world literature. Yet, the distribution of malign tumors displayed geographical differences. Keywords: Salivary gland, parotid, tumors, epidemiology
P16 AND KI-67 EXPRESSION IN HPV RELATED HEAD AND NECK MUCOSAL LESIONS S. Elif Gültekin1, Burcu Sengüven1, Peter Jens Klussmann2, Peter Hans Dienes3, 1 Gazi University Faculty of Dentistry Department of Oral Pathology, Ankara, Turkey; 2Giessen University, Faculty of Medicine, Department of Oto Rhino Laryngeology, Giessen,
WILSON’S DISEASE: IS PULP AFFECTED? Taha Emre Köse1, Onur Dincer Köse2, Hülya Cakır Karabas1, Merva Soluk Tekkes¸in3, 1Department of Dentomaxillofacial Radiology, Istanbul University, Istanbul, Turkey; 2Department of Oral and Maxillofacial Surgery, Istanbul University, Istanbul, Turkey; 3Department of Tumour Pathology, Instıtute of Oncology, Istanbul University, Istanbul, Turkey Wilson’s disease (WD) is an autosomal recessive disorder which was first described as hepatocellular degeneration by Kinnier Wilson in 1912. WD is caused by mutation in ATP7B gene. Defective biliary excretion of copper causes the accumulation of copper in the organs, including liver, brain, kidney, and cornea. This accumulation leads to organ damage. A 28 year-oldmale patient, diagnosed as WD 12 years ago, was referred to our clinic for periodontal complaints. After clinical examination, two molar teeth were extracted and sent to the pathology department for microscopic evaluation. The teeth were decalcified in 10% formic acid solution for two weeks. The decalcified specimens were embedded in paraffin and cut into 5 mm thick sections on charged slides. The sections were stained with orcein to detect possible accumulation of copper. In this case report, we research if there are any particular accumulation and/or degenerative changes in pulp, enamel and dentin. Keywords: Wilson’s disease, pulp, copper accumulation
ODONTOGENICTUMOURS: A MULTICENTRIC RETROSPECTIVE STUDY OF 2000 CASES IN TURKISH POPULATION S. Elif Gültekin1, Burcu Sengüven1, Emre Barıs¸1, Özlem Özer Yücel1, Merva Soluk Tekkes¸in2, Ömer Günhan3, Aysun Uguz4, Demet Etit5, 1Department of Oral Pathology, Faculty of Dentistry, Gazi University, Ankara, Turkey; 2Department of Tumour Pathology, Institute of Oncology, Istanbul University; 3Department of Pathology, Gülhane Military Medical Academy, Ankara, Turkey; 4 Department of Pathology, Faculty of Medicine, Çukurova University, Adana, Turkey; 5Department of Pathology, Fac_ ulty of Medicine, Izmir KatipÇelebi University, Turkey Objective: Data from different countries show significant differences in frequency of odontogenic tumors, which were
OOOO March 2015 derived from epithelial, ectomesenchymal and/or mesenchymal remnants of tooth-forming apparatus. Study Design: Current study describes the epidemiology and clinical presentation of odontogenic tumors from five pathology services from Turkey. The classification was made according to 2005 WHO histological classification. Results: A total of 2000 odontogenic tumor cases retrieved from the archival files between 2002 and 2012 were retrospectively analyzed for gender, age, tumor site and relative frequency of tumor types. Of these tumors only 0.37% was malignant. Keratocystic odontogenic tumor was the most frequent type (57.2%), followed by odontoma (16.7%), and ameloblastoma (15.08%). The mean age of the patients was 35.09and the malefemale ratio was 1: 0.92. Mandible posterior was the most frequent location. Conclusions: The present study confirms the frequency of keratocystic odontogenic tumor and ameloblastoma which are not rare in Turkish population. Keywords: epidemiology, odontogenic tumors
PERICORONAL RADIOLUCENCY ASSOCIATED WITH AN IMPACTED PREMOLAR TOOTH Ülkem Aydın1, Ufuk Ates¸2, Burcu Sengüven3, 1Department of Dentomaxillofacial Radiology, Baskent University, Ankara, Turkey; 2Department of Dentomaxillofacial Surgery, Baskent University, Ankara, Turkey; 3Department of Oral Pathology, Faculty of Dentistry, Gazi University, Ankara, Turkey Aplasia of the mandibular second premolar (MnP2), anomalous distal inclination of the contralateral MnP2 bud and delayed tooth formation is one of the dental anomaly patterns (DAP). In addition, the odontogenic tissue around the impacted tooth has the propensity to differentiate into a wide variety of pathological lesions. Detection of such pathologic lesions usually requires removal of the tooth and the lesion. A systemically healthy 16year-old female patient attended our clinic for follow-up of her impacted tooth. On the panoramic radiograph, a pericoronal radiolucency associated with the distoangularly oriented impacted right MnP2, and aplasia of its antimere was detected. The patient was then referred for surgical operation. Histopathologically, the diagnosis was hyperplastic dental follicle. The purpose of the present report was to present the radiographic and histopathologic features of a case of pericoronal radiolucency associated with an impacted MnP2 and to describe one of the DAP. Keywords: dental anomaly patterns, hyperplastic dental follicle
BISPHOSPHONATE INDUCED MANDIBLE BONE OSTEONECROSIS IN A PATIENT WITH PROSTATE CANCER Ahmet S¸alvarcı1, Serdar Altınay2, 1Novafertil, Department of Urology, Konya, Turkey; 2Ba gcılar Training and Research Hospital, Department of Pathology, Istanbul, Turkey In large series, the incidence of bisphosphonate-associated osteonecrosis is 65% in the lower jaw, 26% in the upper jaw and %9 in both jaws. Androgen-deprivation therapy and third-generation bisphosphonate zoledronic acid treatment was initiated to a 64-year-old patient with metastatic prostate cancer. During the 36th month of treatment the patient presented with swelling of the lower jaw and was diagnosed and treated for abscess. Pain persisted for three months despite the treatment. On physical examination, open wound of the oral mucosal was observed. Computer tomography showed a lesion consistent with bone
OOOO Volume 119, Number 3 necrosis in the lower jaw’s fovea sublingual region. The diagnosis of necrotic bone was made by observing areas characterized by empty osteocyte lacunae in pathological examination. Although it is suggested that oral hygiene education benefits in reducing the risk of bisphosphonate related osteonecrosis, still the risk of developing it is present. Keywords: Bisphosphonate, mandible, bone, osteonecrosis
BIPHASIC MALIGNANT TUMOR OF HYPOPHARYNX: SYNOVIAL SARCOMA? Serdar Altınay1, Salih Aydın2, Ümit Tas¸kın2, 1Bagcılar Training and Research Hospital, Department of Pathology, Istanbul, Turkey; 2Ba gcılar Training and Research Hospital, Department of Ear&Nose&Throat, Istanbul, Turkey Oropharyngeal synovial sarcoma is extremely rare. We present a 44 year old male patient with a lesion elongating through the hypopharynx. The patient was admitted with a 3-4 months history of hoarseness, difficulty of swallowing and pain in the right ear. Physical examination revealed a 3 3 cm mass in the left tonsil causing partial obstruction of the hypopharynx. Partial pharyngectomy and left functional neck dissection were performed. Neoplasms of biphasic morphology were found in the microscopic evaluation of the specimen. Tumor cells showed strong CK7, CK19 and EMA immunoreactivity and Bcl-2, CK5 / 6 and p53 focal staining. S100, CD99, CD31, CD34 staining were negative. Based on its features, this case was reported as a synovial sarcoma like biphasic malignant tumor. Synovial sarcoma should be considered in the differential diagnosis of oropharyngeal region tumors. Genetic analysis is recommended in order not to face a diagnostic dilemma. Keywords: Hypopharynx, synovial sarcoma, biphasic tumor
THYROID FOLLICULAR CARCINOMA METASTASIZED TO THE PARANASAL SINUS, LUNG AND BONE, SHOWING EXTENSIVE CLEAR CELL MORPHOLOGY Serdar Altınay1, Ümit Tas¸kın2, Salih Aydın2, Mehmet Faruk Oktay2, 1Bagcılar Training and Research Hospital, Department of Pathology, Istanbul, Turkey; 2Bagcılar Training and Research Hospital, Department of Ear&Nose&Throat, Istanbul, Turkey Follicular thyroid carcinoma metastasis to the paranasal sinuses is extremely rare. A 68-year-old female patient presented with a history of 2 months of swelling and loss of vision in her left eye. Brain MRI revealed a 68 39 53 mm irregularmargin soft tissue lesion with malign characteristics that showed intense homogenous contrast enhancement. It was mainly localized in the left nasal cavity extending into the left orbit and invading the clivus and sella. Biopsy showed tumor cells of extensive clear cell morphology adjacent to the nasal mucosa. In immunohistochemical studies, diffuse Pan CK staining cells did not show immunoreactivity with GFAP, CD10 and EMA. Immunohistochemistry for thyroid transcription factor-1 (TTF-1), thyroglobulin was markedly positive. The charecteristics of this case are consistent with follicular thyroid carcinoma metastasis. Beside morphologic and immunohistochemical findings, clinical findings are also important in differentiating clear cell tumors morphology. Keywords: Thyroid follicular carcinoma, metastasis, paranasal sinus, lung, bone, clear cell morphology.
ABSTRACTS Abstracts e189 SUSPECTED RECURRENCE IN PATIENT DIAGNOSED WITH SQUAMOUS CELL CARCINOMA OF THE MANDIBLE: ACTINOMYCES INFECTION Serdar Altınay1, S¸enay Yalçın1, Ahmet Cemal Aykıt2, 1Ba gcılar Training and Research Hospital, Department of Pathology, Istanbul, Turkey; 2Kemerburgaz University, Medical Faculty, Department of Aesthetic Plastic Surgery, Istanbul, Turkey Lower lip cancer constitutes 88-98% of the lip cancers. It is a common malignancy of the head and neck region seen mostly in 50 to 60 years old men. The relapse rate is 5% and the second primarily development is also 5% seen after treatment. A 60-yearold male patient presented with left mandible recurrence one year after being diagnosed with lower lip squamous cell carcinoma. Two years later, bone and soft tissue material of the same region were examined with the recurrence suspicion. All the material microscopic examination revealed. Evidence of primary and / or metastatic neoplasms was not observed. PAS stained Actinomyces infection was noticed between the trabecular of the bone tissue. In practicing oncologic pathology it is important not to focus only on the tumor but to keep in mind the possible presence of non-tumor lesion. Keywords: Recurrence, squamous cell carcinoma, mandible, actinomyces infection
HISTOPATHOLOGICAL DIVERSITY OF PAROTIDECTOMY MATERIALS IN TURKISH POPULATION: RETROSPECTIVE ANALYSIS OF 136 CASES Serdar Altınay1, Ümit Tas¸kın2, Salih Aydın2, Mehmet Sar3, 1 Ba gcılar Training and Research Hospital, Department of Pathology, Istanbul, Turkey; 2Ba gcılar Training and Research Hospital, Department of Ear & Nose & Throat, Istanbul, Turkey; 3Bakırköy DrSadi Konuk Training and Research Hospital, Department of Pathology, Istanbul, Turkey Objective: We have aimed to compare the demographic data in parotid tumors with the data in literature. Study Design: This study was conducted retrospectively on 136 parotidectomy materials operated in our clinic between May 2009-May 2013. Their age, gender, tumor diameter, histopathological diagnosis and surgical margin status were recorded. Results: The benign cases were 112 (82.4%), while the malignant cases were 24 (17.6%). Warthin tumor was more apparent in males (p<0.05). Pleomorphic Adenoma was detected most frequently among benign pathologies at 61.6% (69/112), while the Warthin Tumor was detected as the second. Mucoepidermoid Carcinoma and Carcinoma ex Pleomorphic Adenoma was detected at equal frequency at 20.8% (5/24) among malign tumors. While the surgical margin was positive in 10 patients among malign tumors (41.7%), all of the benign tumors were negative (p<0.01). Conclusions: Pleomorphic adenoma was the most frequently reported benign tumor almost in all world literature. Yet, the distribution of malign tumors displayed geographical differences. Keywords: Salivary gland, parotid, tumors, epidemiology
P16 AND KI-67 EXPRESSION IN HPV RELATED HEAD AND NECK MUCOSAL LESIONS S. Elif Gültekin1, Burcu Sengüven1, Peter Jens Klussmann2, Peter Hans Dienes3, 1 Gazi University Faculty of Dentistry Department of Oral Pathology, Ankara, Turkey; 2Giessen University, Faculty of Medicine, Department of Oto Rhino Laryngeology, Giessen,