Publications by authors named "Regina Helena Garcia Martins"

63 Publications

Effect of Aging on the Vocal Muscle.

J Voice 2022 Apr 15. Epub 2022 Apr 15.

Otorhinolaryngology, and Head and Neck Surgery Department, Botucatu Medical School, Unesp, São Paulo, Brazil; Otorhinolaryngology, and Head and Neck Surgery Department, Botucatu Medical School, Unesp, São Paulo, Brazil. Electronic address:

Introduction: Sarcopenia is a common and natural condition in the elderly, and leads to loss of muscle mass and function. In the presbylarynx there is atrophy of the vocal folds, however the degree of vocal muscle atrophy is poorly studied and the results are contradictory.

Aims: The aim of this study was to evaluate the effect of aging on the vocal muscle (thyroarytenoid muscle).

Methods: Thirteen larynxes removed during necropsy from 13 cadavers were included into two age groups: Control group - G1 (n5), between 25 and 40 years; Elderly Group - GI (n-8), aged 70 years or older. The vocal folds were dissected and prepared for scanning electron microscopy, ensuring a cross-section in the musculature area to allow measurements of muscle fiber parameters. Images were analyzed and photographed at different magnifications. Through the ImageJ software, ten distinct fields of each part were selected. Parameters studied:  area, perimeters and diagonals of the thyroarytenoid muscle bundles of both groups.

Results: The cross-sectional areas, perimeters and diagonals of the muscle fibers of the thyroarytenoid muscle of the elderly group were significantly smaller than those of the control group.

Conclusion: We demonstrated that the vocal muscle is affected in the presbylarynx, with a reduction of its muscle fibers, corresponding to muscle atrophy. However, these findings may not be directly related to vocal symptoms because the patient may develop muscle compensatory mechanisms capable of reducing glottic insufficiency.
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http://dx.doi.org/10.1016/j.jvoice.2022.03.020DOI Listing
April 2022

Does Abrupt Weight Loss Caused by Bariatric Surgery Compromise the Voice in Women?

J Voice 2021 Apr 5. Epub 2021 Apr 5.

Department of Ophthalmology, Otorhinolaryngology, Head and Neck Surgery, São Paulo State University, Botucatu, SP, Brazil. Electronic address:

Objective: To evaluate vocal symptoms, voice characteristics and videolaryngoscopy in obese women before and after bariatric surgery.

Methods: Obese patients (18 to 59 years old), candidates for bariatric surgery were recruited. Evaluation times: T1 (preoperative), T2 (after six months), T3 (after 12 months). Evaluated parameters: weight, height, body mass index, abdominal and neck circumference, vocal self-assessment, perceptual and acoustic vocal assessment, and videolaryngoscopy.

Results: A total of 37 obese women were included, average age 40.8 years. There was a decrease in anthropometric measurements between the preoperative assessment and after 12 months: weight (121.18 ± 15.4 kg; 77.1 ± 11.6 kg), BMI (46.6 ± 6.95 kg/m; 30 ± kg/m), abdominal circumference (128 ± 16.1; 99.1 ± 12.1), and neck circumference (41.1 ± 5.85; 36.6 ± 3.02). Gastroesophageal (21.6%) and vocal symptoms (27%) prevailed. No difference was identified in vocal self-assessment between the evaluations. In the acoustic analysis, f0 increased and the soft phonation index decreased. The perceptual analysis registered lower scores for the degree of dysphonia (G) and voice instability (I). The maximum phonation time values increased without changing the s/z ratio. Videolaryngoscopies showed a posterior middle cleft and improvement in the signs of reflux.

Conclusions: Bariatric surgery led to an important and gradual decrease in anthropometric parameters. The voice became less hoarse, with higher pitch and more stable, with an improvement in maximum phonation time, however with slight breathiness. Such changes were not noticed by the patients.
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http://dx.doi.org/10.1016/j.jvoice.2021.03.007DOI Listing
April 2021

An estimate of the incidence and prevalence of laryngeal papillomatosis in São Paulo State (Brasil).

Rev Assoc Med Bras (1992) 2020 Sep;66(9):1247-1251

MD. PhD. Livre Docência. Otorrinolaringologista. Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço da Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, São Paulo, Brasil.

Background: Recurrent laryngeal papillomatosis, caused by the Human Papilloma Virus, has a significant economic impact worldwide and there are no epidemiological data of this disease in Brasil.

Objective: The objective of the study was to estimate the incidence and prevalence of laryngeal papillomatosis of some otorhinolaryngology centers in São Paulo State (Brasil).

Methods: A questionnaire containing data on the number of new and follow-up cases diagnosed with laryngeal papillomatosis was sent to the Otorhinolaryngology services (n=35) of São Paulo State (Brasil).

Results: A total of 20 otorhinolaryngology centers answered the questionnaire. Of these, the five largest regional health centers were selected as follows: Campinas (42 cities - 4,536,657 inhabitants), Sao Jose do Rio Preto (102 cities - 1,602,845 inhabitants), Ribeirão Preto (26 cities - 1,483,715 inhabitants), Bauru (68 cities - 1,770,427 inhabitants), and Sorocaba (47 cities - 2,478,208 inhabitants). The incidence and prevalence of each regional health centers were, respectively: Campinas (5.51;7.27), Sorocaba (2.02;6.86), São José do Rio Preto (1.87;7.49), Ribeirão Preto (11.46;22.92), and Bauru (3.95;7.91).

Conclusion: The incidence and prevalence of the laryngeal papillomatosis of the five largest regional health centers of the interior of São Paulo State (Brasil) varied between 1.87 to 11.46 and 6.86 to 22.92 per 1,000,000 inhabitants, respectively for a total population of 11,871,852 inhabitants.
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http://dx.doi.org/10.1590/1806-9282.66.9.1247DOI Listing
September 2020

Sectorial Analysis of the Fibrous Matrix of Vocal Folds in the Elderly.

J Voice 2022 May 4;36(3):309-315. Epub 2020 Aug 4.

Institute of Bioscience. Department of Morphology, Univ. Estadual Paulista (Unesp), Botucatu, São Paulo, Brazil.

Objective: to determine the sectorial concentration of fibrous matrix along the vocal folds of the elderly.

Methods: Thirteen fresh vocal folds were removed from 13 cadavers. The subjects were divided into two groups: control group (CG) - age range 25-40 years (n = 5), and elderly group (EG), aged ≥70 years (n-8). The vocal folds were separated according to regions in: anterior macula flava (AMF), posterior macula flava (PMF), medial region (M) and lateral region of the membranous vocal fold (L). The material was examined using a scanning electron microscope and 10 pictures per region were obtained at 1200x magnification. The area of fibrous matrix was quantified in both groups using the AVSOFT Biovew Program.

Results: Percentage (%) of fibrous matrix per region (%): AMF (EG = 86.78%; CG = 81.63%); PMF (EG = 88.19%; CG = 81.52%); M (EG = 84.92%; CG = 77.96%); L (EG = 83.93%; CG = 78.91%). Irregular distribution of a dense fibrous matrix was also more evident in the elderly's larynges in a qualitative assessments.

Conclusion: A higher concentration of fibrous matrix was observed in the vocal folds of the elderly when compared to the control at all the studied regions. The greatest increase in the concentration of fibers in the medial portion of the body of the vocal folds is probably due to the phonatory stimulation. The macula flava remains functional even in the senile larynx.
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http://dx.doi.org/10.1016/j.jvoice.2020.07.003DOI Listing
May 2022

Vocal Characteristics of Patients With Morbid Obesity.

J Voice 2021 Mar 21;35(2):329.e7-329.e11. Epub 2019 Oct 21.

Department of Surgery, São Paulo State University (Unesp), Botucatu, Sao Paulo, Brazil.

Introduction: Obesity modifies vocal characteristics, causing abnormal fat deposition in the abdominal region and upper airways. For some authors the voice of the obese is not different from nonobese and the vocal symptoms are scarce; for others dysphonia in obese is reported by 70% of them and the voice becomes hoarse, breathy, and unstable.

Objective: To characterize the voice of patients with morbid obesity.

Methods: Two groups were included: Obese (n-27), aged between 26 and 59 years, selected for bariatric surgery; Control (n-27), matched in age, with ideal weight for height.

Parameters: Vocal self-assessment (Vocal Disadvantage Index-IDV and Quality of Life and Voice-QVV); Perceptual-auditory vocal evaluation (GRBASI scale), maximum phonation time; Acoustic vocal analysis and Videolaryngoscopic exams.

Results: In obese, the most frequent symptoms were gastroesophageal and hoarseness. The vocal self-evaluation did not record any relevant complaints in both groups. In obese, the perceptual-auditory voice evaluations indicated significant changes in R (roughness), B (breathiness), I (instability), and S (tension) parameters. Acoustic vocal analysis recorded changes in the noise-harmonic ratio (NHR) and soft phonation index (SPI) parameters. The videolaryngoscopy examinations showed, in control and obese groups, respectively: normal: 92.5% and 55.5%; posterior pachydermia: 11.1% and 33.3%; mid-posterior bowing: 0% and 7.4%; edema/congestion: 0% and 7.40%.

Conclusion: The voice of the obese becomes discreetly hoarse, breathless, and unstable. The most frequent videolaryngoscopic findings in obese patients are hyperemia and edema of vocal folds and posterior pachydermia, related to acid laryngitis, secondary to gastroesophageal reflux.
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http://dx.doi.org/10.1016/j.jvoice.2019.09.012DOI Listing
March 2021

Laryngeal Microsurgery for the Treatment of Vocal Nodules and Cysts in Dysphonic Children.

Folia Phoniatr Logop 2020 19;72(4):325-330. Epub 2019 Sep 19.

Department of Ophthalmology, Otorhinolaryngology, Head and Neck Surgery, Botucatu Medical School, University of Estadual Paulista, Botucatu, Brazil.

Introduction: Vocal nodules and cysts are frequent causes of infantile dysphonia. Vocal therapy is the first treatment. Microsurgery has restricted indications, especially for nodules.

Objective: To describe our experience with microsurgery for nodules and cysts in children.

Methods: Dysphonic children (aged 4-18 years) with the diagnosis of nodules and vocal cysts were initially selected. Of these children, only those were included who had undergone microsurgery. For nodules and cysts, the microsurgery was indicated in cases of failure of vocal therapy and in cases of voice worsening or doubts about the diagnosis. All children were submitted to auditory perceptual vocal analysis and videolaryngostroboscopy (before and after surgery, after 6 months). Surgical outcomes were: total improvement (disappearance of vocal symptoms and of the laryngeal lesions); partial improvement (partial improvement of symptoms and/or maintenance of lesions); no improvement (maintenance or worsening of the symptoms and/or persistence of the lesions). -Results: There were 78 children with vocal nodules and 27 children with vocal cysts. Surgery was indicated for 12 children with vocal nodules (15.4%) and 12 children with cysts (44.4%). Total improvement registered for nodules and cysts was 75 and 83.4%, respectively. Partial improvement for both lesions was 25 and 16.6%, respectively.

Conclusion: The best outcome for laryngeal microsurgery in dysphonic children was for vocal cysts. So, we encourage laryngologists for this conduct in vocal cysts. The success of microsurgery for vocal nodules was lower, and in these cases voice therapy seems to be the best treatment.
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http://dx.doi.org/10.1159/000502477DOI Listing
November 2021

Treatment of Laryngeal Granulomas.

Int Arch Otorhinolaryngol 2019 Jul 28;23(3):e322-e324. Epub 2019 May 28.

Botucatu Medical School, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Universidade Estadual Paulista, Botucatu, São Paulo, SP, Brazil.

 Laryngeal granulomas are benign, recurrent lesions of many causes (reflux, voice abuse, intubation, and idiopathic), which renders its treatment difficult.  To describe our experience in the treatment of laryngeal granulomas.  From 16 medical records of the patients with laryngeal granulomas seen between 2010 and 2017 in a university hospital, the following data were analyzed: age, gender, vocal and gastroesophageal symptoms, vocal overuse, intubation, treatments, videolaryngoscopy before and after the treatment.  Gender: female, 10; male, 6. Age: between 20 and 60 years old (11). Etiology of the granulomas: intubation (9), reflux (4), idiopathic (3). The initial treatments adopted in all cases were: inhaled beclomethasone dipropionate 100 µg 12/12 hours (1 month), proton pump inhibitor, omeprazole 40 mg/day (2 months), and dietary and voice education. After this period, 10 patients (7 postintubation, 3 idiopathic) were submitted to surgery, since no improvements in the symptoms or in the lesions were seen. Of these, two recurred, requiring a second surgery, one of which recurred six times and received botulinum toxin A. Only one patient with granulomas due to laryngopharyngeal reflux presented no improvement in the symptoms nor in the lesion after the pharmacological treatment and had been submitted to microsurgery. All of the other patients with reflux granulomas were successfully treated with the drug treatment, and the longest treatment time for complete remission of the symptoms and of the lesions was 9 months.  In laryngeal granulomas caused by reflux, treatment with inhaled steroids and proton pump inhibitors proved to be effective, although prolonged. In postintubation and idiopathic granulomas, surgery was the best treatment.
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http://dx.doi.org/10.1055/s-0039-1688456DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6660291PMC
July 2019

Laryngeal Web as a Possible Cause for Nonabsorption of Vocal Nodules in Boys After Puberty.

J Voice 2019 Jul 14;33(4):561-563. Epub 2018 Sep 14.

Ophthalmology, Otorhinolaryngology and Head and Neck Surgery Department, Botucatu Medical School, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil.

Objectives: Vocal nodules are frequent in children and tend to be reabsorbed after puberty, especially in boys. The aims of the present study were to analyze the progression of nodules in boys after puberty and to investigate the role of microweb in the persistence of these lesions.

Methods: Clinical and videolaryngoscopy evaluations were carried out in boys with vocal nodules treated between 2009 and 2016, followed up to the age of 17 years or until remission of symptoms and reabsorption of the nodules. Boys with vocal nodules who underwent regular vocal therapy are included in the study. The outcomes were remission of symptoms and of the nodular lesions.

Results: A total of 34 boys with vocal nodules were diagnosed, of which 21 completed follow-up. Mean age of the first evaluation was 9 years (5-11 years) and of end of treatment was 14 years (13-18 years). Mean number of videolaryngoscopy per child was five. After adolescence there was complete remission of symptoms and of the lesions in 15 children (71.4%), partial remission in four (19.0%), and no remission of symptoms and of the lesions in two cases. In these two, videolaryngoscopy identified the presence of microweb and nodules.

Conclusions: Favorable reabsorption of the vocal nodules after adolescence was observed in the majority of the boys who underwent voice therapy; however, in two cases there was no remission of symptoms and of the lesions. The unfavorable course can be attributed to anterior laryngeal microwebs.
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http://dx.doi.org/10.1016/j.jvoice.2017.12.017DOI Listing
July 2019

Treatment of post-intubation laryngeal granulomas: systematic review and proportional meta-analysis.

Braz J Otorhinolaryngol 2018 Nov - Dec;84(6):781-789. Epub 2018 Apr 14.

Universidade Estadual Paulista (Unesp), Faculdade de Medicina de Botucatu, Departamento de Cirurgia, Botucatu, SP, Brazil.

Introduction: Laryngeal granulomas post intubation are benign but recurrent lesions. There is no consensus for its treatment.

Objective: To describe the effectiveness of different treatment modalities for primary or recurrent laryngeal granulomas resulting from endotracheal intubation.

Methods: Systematic review and proportional meta-analysis. Eligibility criteria - experimental or observational studies with at least five subjects. Outcomes studied - granuloma resolution, recurrence, and time for resolution. Databases used - Pubmed, Embase, Lilacs, and Cochrane. The Stats Direct 3.0.121 program was used.

Results: Six studies were selected, with 85 patients. The treatments registered were: antireflux therapy, speech therapy, anti-inflammatory drugs, steroids, antibiotics, zinc sulfate and surgery. 85 patients from six studies had primary treatment: surgery±associations (41 patients), resolution chance 75% (95% CI: 0.3-100%, I=90%), absolute relapse risk 25% (95% CI: 0.2-71%); medical treatment (44 patients), resolution chance 86% (95% CI: 67-97%); and absolute relapse risk 14% (95% CI: 3-33%). There was no significant difference between groups. Three studies, encompassing 19 patients, analyzed secondary treatment (failure or recurrence after primary treatment); three subjects presented new recurrence. The time needed to resolve the lesions varied from immediate, after surgery, to 23 months, for inhaled steroid.

Conclusion: There is no evidence of high quality that proves the efficacy of any treatment for laryngeal granulomas resulting from endotracheal intubation.
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http://dx.doi.org/10.1016/j.bjorl.2018.03.003DOI Listing
December 2018

Laryngeal and vocal alterations after thyroidectomy.

Braz J Otorhinolaryngol 2019 Jan - Feb;85(1):3-10. Epub 2017 Sep 21.

Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), Disciplina de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Botucatu, SP, Brazil. Electronic address:

Introduction: Dysphonia is a common symptom after thyroidectomy.

Objective: To analyze the vocal symptoms, auditory-perceptual and acoustic vocal, videolaryngoscopy, the surgical procedures and histopathological findings in patients undergoing thyroidectomy.

Methods: Prospective study. Patients submitted to thyroidectomy were evaluated as follows: anamnesis, laryngoscopy, and acoustic vocal assessments. Moments: pre-operative, 1st post (15 days), 2nd post (1 month), 3rd post (3 months), and 4th post (6 months).

Results: Among the 151 patients (130 women; 21 men). Type of surgery: lobectomy+isthmectomy n=40, total thyroidectomy n=88, thyroidectomy+lymph node dissection n=23. Vocal symptoms were reported by 42 patients in the 1st post (27.8%) decreasing to 7.2% after 6 months. In the acoustic analysis, f0 and APQ were decreased in women. Videolaryngoscopies showed that 144 patients (95.3%) had normal exams in the preoperative moment. Vocal fold palsies were diagnosed in 34 paralyzes at the 1st post, 32 recurrent laryngeal nerve (lobectomy+isthmectomy n=6; total thyroidectomy n=17; thyroidectomy+lymph node dissection n=9) and 2 superior laryngeal nerve (lobectomy+isthmectomy n=1; Total thyroidectomy+lymph node dissection n=1). After 6 months, 10 patients persisted with paralysis of the recurrent laryngeal nerve (6.6%). Histopathology and correlation with vocal fold palsy: colloid nodular goiter (n=76; palsy n=13), thyroiditis (n=8; palsy n=0), and carcinoma (n=67; palsy n=21).

Conclusion: Vocal symptoms, reported by 27.8% of the patients on the 1st post decreased to 7% in 6 months. In the acoustic analysis, f0 and APQ were decreased. Transient paralysis of the vocal folds secondary to recurrent and superior laryngeal nerve injury occurred in, respectively, 21% and 1.3% of the patients, decreasing to 6.6% and 0% after 6 months.
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http://dx.doi.org/10.1016/j.bjorl.2017.08.015DOI Listing
February 2019

Transmission Electron Microscopy of the Presbylarynx in the Process of Voice Aging.

J Voice 2018 Jan 10;32(1):3-7. Epub 2017 Oct 10.

Department of Ophthalmology, Otorhinolaryngology and Head Neck Surgery, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil.

Introduction: Microscopy studies of presbylarynx have identified epithelial atrophy, as well as vocal muscle atrophy, increased collagen, and decreased nonfibrous proteins of the extracellular matrix. Studies on the ultrastructure of presbylarynx are rare and can help us understand the pathophysiology of presbyphonia.

Objective: To describe details on the ultrastructure of presbylarynx by transmission electron microscopy (TEM).

Subjects And Methods: Sixteen human larynges were removed and distributed in two groups: control (n = 8; 30-50 years; six females, two males) and seniors (n = 8; 75-92 years; six females, two males). After preparation for TEM, the specimens, including epithelium and lamina propria, were examined and photographed at increasing magnification.

Results: Control: the epithelium was intact, with overlapped cells, and with desmosomes between the intercellular junctions. The basement membrane was continuous and uniform, and the lamina propria contained collagen and elastic fibers in a regularly distributed loose arrangement, as well as some fibroblasts of different shapes. Senior: the epithelial cells were separated by enlarged intercellular junctions. The basement membrane was delicate and continuous. In the lamina propria there was predominance of elongated fibroblasts. Under the basement membrane a dense network of collagen fibers could be identified.

Conclusions: In this study with TEM some structural changes were identified, particularly in the larynx of the elderly, both in the epithelium and lamina propria, some of them with likely participation of fibroblasts, which reinforces the importance of additional ultrastructure as well as molecular studies targeting those cells, as they are the main precursors of the components of the extracellular matrix.
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http://dx.doi.org/10.1016/j.jvoice.2016.11.013DOI Listing
January 2018

Bilateral vallecular cysts.

Braz J Otorhinolaryngol 2020 Dec 5;86 Suppl 1:6-7. Epub 2016 Nov 5.

Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP), Faculdade de Medicina de Botucatu, Departamento de Oftalmologia e Otorrinolaringologia, Botucatu, SP, Brazil. Electronic address:

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http://dx.doi.org/10.1016/j.bjorl.2016.10.003DOI Listing
December 2020

Are Vocal Alterations Caused by Smoking in Reinke's Edema in Women Entirely Reversible After Microsurgery and Smoking Cessation?

J Voice 2017 May 21;31(3):380.e11-380.e14. Epub 2016 Jul 21.

Speech Therapy, Discipline of Otolaryngology, UNESP Universidade Estadual Paulista, Botucatu, São Paulo, Brazil.

Background: Reinke's edema is a benign lesion of the vocal folds that affects chronic smokers, especially women. The voice becomes hoarse and virilized, and the treatment is microsurgery. However, even after surgery and smoking cessation, many patients remain with a deep and hoarse voice.

Objectives: The aim of the present study was to compare pre- and postoperative acoustic and perceptual-auditory vocal analyses of women with Reinke's edema and of women in the control group, who were non-smokers.

Methods: A total of 20 women with videolaryngoscopy diagnosis of Reinke's edema who underwent laryngeal microsurgery were evaluated pre- and postoperatively (6 months) by videolaryngoscopy, acoustic voice, and perceptual-auditory analyses (General degree of dysphonia, Roughness, Breathiness, Asthenia, Strain, and Instability [GRBASI] scale), and the maximum phonation times were calculated. The pre- and postoperative parameters of the women with Reinke's edema were compared with those of the control group of women with no laryngeal lesions, smoking habit, or vocal symptoms.

Results: Acoustic vocal perceptual-auditory analyses and the maximum phonation time of women with Reinke's edema improved significantly in the postoperative evaluations; nevertheless, 6 months after surgery, their voices became worse than the voices of the women from the control group.

Conclusions: Abnormalities caused by smoking in Reinke's edema in women are not fully reversible with surgery and smoking cessation. One explanation would be the presence of possible structural alterations in fibroblasts caused by the toxicity of cigarette components, resulting in the uncontrolled production of fibrous matrix in the lamina propria, and preventing complete vocal recovery.
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http://dx.doi.org/10.1016/j.jvoice.2016.06.012DOI Listing
May 2017

Scanning Electron Microscopy of the Presbylarynx.

Otolaryngol Head Neck Surg 2016 06 22;154(6):1073-8. Epub 2016 Mar 22.

Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Univ Estadual Paulista, Botucatu Medical School (Unesp), Botucatu (SP), Brazil

Objective: To describe the findings on the presbylarynx under scanning electron microscopy.

Study Design: Cadaver study.

Setting: Universidade Estadual Paulista (Botucatu, São Paulo, Brazil).

Subjects And Methods: Sixteen vocal folds were removed during necropsies and distributed into 2 age groups: control (n = 8; aged 30-50 years) and elderly (n = 8; aged 75-92 years). The right vocal fold was dissected, fixed in glutaraldehyde 2.5%, and prepared for scanning electron microscopy. The thickness of the epithelium was measured using a scandium morphometric digital program.

Results: In the control group, the epithelium had 5 to 7 overlapped cell layers, rare desquamation cells, and little undulation with protruding intercellular junctions. The lamina propria showed a uniform network of collagen and elastic fibers in the superficial layer. A dense network of collagen was identified in the deeper layer. In the elderly group, the epithelium was atrophic (2-3 cells), with more desquamation cells and intercellular junctions delimited by deep sulci. The epithelial thickness was lower in elderly than in controls (mean [SD], 221.64 [145.90] µm vs 41.79 [21.40] µm, respectively). The lamina propria had a dense and irregular distribution of collagen and elastic fibers in the superficial layer. In the deep layers, the collagen fibers formed a true fibrotic and rigid skeleton.

Conclusion: Scanning electron microscopy identified several changes in the elderly larynx, differentiating it from the controls. These alterations are probably related to the aging process of the vocal folds. However, the exact interpretation of these findings requires additional studies, even to the molecular level, having the fibroblasts as targets.
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http://dx.doi.org/10.1177/0194599816637081DOI Listing
June 2016

Ortner's syndrome: a rare cause of sudden hoarseness in the older person.

Age Ageing 2016 Jan 11;45(1):177. Epub 2015 Nov 11.

Ophtalmology, Otorhinolaryngology and Head and Neck Surgery, Univ. Estadual Paulista, Botucatu, São Paulo, Brazil.

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http://dx.doi.org/10.1093/ageing/afv153DOI Listing
January 2016

Voice Disorders: Etiology and Diagnosis.

J Voice 2016 Nov 4;30(6):761.e1-761.e9. Epub 2015 Nov 4.

Ophthalmology, Otorhinolaryngology, Head and Neck Surgery Department, Botucatu Medical School, UNESP-Universidade Estadual Paulista, Botucatu, São Paulo, Brazil.

Objectives: Voice disorders affect adults and children and have different causes in different age groups. The aim of the study is to present the etiology and diagnosis dysphonia in a large population of patients with this voice disorder.for dysphonia of a large population of dysphonic patients.

Methods: We evaluated 2019 patients with dysphonia who attended the Voice Disease ambulatories of a university hospital. Parameters assessed were age, gender, profession, associated symptoms, smoking, and videolaryngoscopy diagnoses.

Results: Of the 2019 patients with dysphonia who were included in this study, 786 were male (38.93%) and 1233 were female (61.07). The age groups were as follows: 1-6 years (n = 100); 7-12 years (n = 187); 13-18 years (n = 92); 19-39 years (n = 494); 41-60 years (n = 811); and >60 years (n = 335). Symptoms associated with dysphonia were vocal overuse (n = 677), gastroesophageal symptoms (n = 535), and nasosinusal symptoms (n = 497). The predominant professions of the patients were domestic workers, students, and teachers. Smoking was reported by 13.6% patients. With regard to the etiology of dysphonia, in children (1-18 years old), nodules (n = 225; 59.3%), cysts (n = 39; 10.3%), and acute laryngitis (n = 26; 6.8%) prevailed. In adults (19-60 years old), functional dysphonia (n = 268; 20.5%), acid laryngitis (n = 164; 12.5%), and vocal polyps (n = 156; 12%) predominated. In patients older than 60 years, presbyphonia (n = 89; 26.5%), functional dysphonia (n = 59; 17.6%), and Reinke's edema (n = 48; 14%) predominated.

Conclusions: In this population of 2019 patients with dysphonia, adults and women were predominant. Dysphonia had different etiologies in the age groups studied. Nodules and cysts were predominant in children, functional dysphonia and reflux in adults, and presbyphonia and Reinke's edema in the elderly.
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http://dx.doi.org/10.1016/j.jvoice.2015.09.017DOI Listing
November 2016

Aging voice and the laryngeal muscle atrophy.

Laryngoscope 2015 Nov 7;125(11):2518-21. Epub 2015 Jul 7.

Department of Anatomy, Institute of Bioscience-UNESP, Univ Estadual Paulista, Botucatu, SP, Brazil.

Objectives/hypothesis: To study by means of morphometric measurements the severity of vocal muscle atrophy in the elderly.

Study Design: Cadaver study.

Setting: Universidade Estadual Paulista (UNESP), Botucatu Medical School, Brazil.

Subjects And Methods: Thirty vocal folds were collected from necropsies distributed into three groups: aged 60 to 75 years (n=10); aged 76 to 90 years (n=10); and a control group aged 30 to 50 years (n=10). Specimens for histology were obtained from the middle portion of the vocal folds. The stained specimens were analyzed using Axion Vision software (coupled to a Zeiss [Oberkochen, Germany] microscope) and used in the morphometric analyses conducted with the ImageJ software. The diameters of 200 muscle fibers from each slide were measured, and the mean values were statistically analyzed.

Results: The mean values of the diameters of the vocal muscle fibers of the elderly age groups were smaller than in the control: control (30-50 years: 16.389 μm); elderly (60-75 years: 14.412 μm; 76-90 years: 14.162 μm) (P<0.01). No statistical differences were observed between genders.

Conclusion: The morphometric analysis showed smaller diameters of vocal muscle fibers in the elderly when compared to controls, demonstrating the atrophy of the muscle. No statistical differences were observed between genders.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1002/lary.25398DOI Listing
November 2015

Voice Disorders in Teachers: Clinical, Videolaryngoscopical, and Vocal Aspects.

J Voice 2015 Sep 19;29(5):564-71. Epub 2015 Feb 19.

Department of Otolaryngology, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil; Department of Ophtalmology, Otorhinolaryngology and Head and Neck Surgery, Botucatu Medical School, Univ. Estadual Paulista, Botucatu, São Paulo, Brazil. Electronic address:

Goal: Dysphonia is more prevalent in teachers than among the general population. The objective of this study was to analyze clinical, vocal, and videolaryngoscopical aspects in dysphonic teachers.

Methods: Ninety dysphonic teachers were inquired about their voice, comorbidities, and work conditions. They underwent vocal auditory-perceptual evaluation (maximum phonation time and GRBASI scale), acoustic voice analysis, and videolaryngoscopy. The results were compared with a control group consisting of 90 dysphonic nonteachers, of similar gender and ages, and with professional activities excluding teaching and singing.

Results: In both groups, there were 85 women and five men (age range 31-50 years). In the controls, the majority of subjects worked in domestic activities, whereas the majority of teachers worked in primary (42.8%) and secondary school (37.7%). Teachers and controls reported, respectively: vocal abuse (76.7%; 37.8%), weekly hours of work between 21 and 40 years (72.2%; 80%), under 10 years of practice (36%; 23%), absenteeism (23%; 0%), sinonasal (66%; 20%) and gastroesophageal symptoms (44%; 22%), hoarseness (82%; 78%), throat clearing (70%; 62%), and phonatory effort (72%; 52%). In both groups, there were decreased values of maximum phonation time, impairment of the G parameter in the GRBASI scale (82%), decrease of F0 and increase of the rest of acoustic parameters. Nodules and laryngopharyngeal reflux were predominant in teachers; laryngopharyngeal reflux, polyps, and sulcus vocalis predominated in the controls.

Conclusions: Vocal symptoms, comorbidities, and absenteeism were predominant among teachers. The vocal analyses were similar in both groups. Nodules and laryngopharyngeal reflux were predominant among teachers, whereas polyps, laryngopharyngeal reflux, and sulcus were predominant among controls.
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http://dx.doi.org/10.1016/j.jvoice.2014.09.019DOI Listing
September 2015

Alterations in extracellular matrix composition in the aging larynx.

Otolaryngol Head Neck Surg 2015 Feb;152(2):302-7

Ophthalmology, Otorhinolaryngology, Head and Neck Surgery Department, Botucatu Medical School, UNESP-Univ Estadual Paulista, São Paulo, Brazil

Objective: To study by immunohistochemistry the alterations of collagens I, III, IV, and V and elastin in the aging process of the human larynx.

Study Design: Cadaver study.

Setting: Universidade Estadual Paulista, Botucatu Medical School, São Paulo State University (UNESP), Brazil.

Subjects And Methods: Thirty vocal folds were obtained at autopsy from 10 adult men (aged 30 to 50 years) and 20 geriatric men (10 aged 60 to 75 years and 10 aged >75 years). Mid membranous vocal fold slides were subjected to immunohistochemical reactions. Digital imaging software (ImageJ) was used to quantify the increase in brownish staining of the lamina propria structures of vocal folds, from superficial to deep layers.

Results: There was an increase of collagen I and III immunoexpression in the elderly larynges, in both layers. Collagens IV and V were immunoexpressed in the vessels endothelium of the lamina propria and in the basement membrane. The immunoexpression of elastin decreased in the elderly larynges, in both lamina propria layers of the vocal folds.

Conclusion: A clear increase of collagens I and III and a decrease of elastic fibers were observed in the lamina propria of vocal folds. The concentration of collagens IV and V was the same across age groups. These findings suggest that as men age, the density of the extracellular matrix increases, brought about by an increase in collagen, while the loss of elastin results in decreased viscoelasticity.
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http://dx.doi.org/10.1177/0194599814562727DOI Listing
February 2015

Psychogenic dysphonia: diversity of clinical and vocal manifestations in a case series.

Braz J Otorhinolaryngol 2014 Nov-Dec;80(6):497-502. Epub 2014 Sep 16.

Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP), Botucatu, SP, Brazil.

Introduction: Psychogenic dysphonia is a functional disorder with variable clinical manifestations.

Objective: To assess the clinical and vocal characteristics of patients with psychogenic dysphonia in a case series.

Methods: The study included 28 adult patients with psychogenic dysphonia, evaluated at a University hospital in the last ten years. Assessed variables included gender, age, occupation, vocal symptoms, vocal characteristics, and videolaryngostroboscopic findings.

Results: 28 patients (26 women and 2 men) were assessed. Their occupations included: housekeeper (n=17), teacher (n=4), salesclerk (n=4), nurse (n=1), retired (n=1), and psychologist (n=1). Sudden symptom onset was reported by 16 patients and progressive symptom onset was reported by 12; intermittent evolution was reported by 15; symptom duration longer than three months was reported by 21 patients. Videolaryngostroboscopy showed only functional disorders; no patient had structural lesions or changes in vocal fold mobility. Conversion aphonia, skeletal muscle tension, and intermittent voicing were the most frequent vocal emission manifestation forms.

Conclusions: In this case series of patients with psychogenic dysphonia, the most frequent form of clinical presentation was conversion aphonia, followed by musculoskeletal tension and intermittent voicing. The clinical and vocal aspects of 28 patients with psychogenic dysphonia, as well as the particularities of each case, are discussed.
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http://dx.doi.org/10.1016/j.bjorl.2014.09.002DOI Listing
March 2015

Hyaluronic acid behavior in the lamina propria of the larynx with advancing age.

Otolaryngol Head Neck Surg 2014 Oct 5;151(4):652-6. Epub 2014 Aug 5.

Head and Neck Surgery Department, Univ Estadual Paulista, Botucatu Medical School, Ophthalmology, Otorhinolaryngology, São Paulo, Brazil

Objectives: To analyze the hyaluronic acid behavior in the lamina propria of the larynx with advancing age.

Study Design: Prospective study.

Setting: UNESP-Univ Estadual Paulista, Botucatu Medical School, Brazil.

Subjects And Methods: Thirty vocal folds were obtained at necropsy from 10 adult males (30-50 years old) and 20 geriatric males (10: 60-75 years old; 10: over 76 years old). Midmembranous vocal fold sections were subjected to immunohistochemical reactions. Digital imaging software (ImageJ) was used to quantify the hyaluronic acid distribution over the lamina propria of vocal folds, from superficial to deep layers.

Results: Hyaluronic acid distribution was homogeneous for the larynges, at both superficial and deep layers (41.6 and 38.5, respectively). For both 30- to 50-year-old men geriatric age groups, hyaluronic acid level was lower at both layers.

Conclusion: Hyaluronic acid level in the lamina propria of the larynx of geriatric men decreases with advancing age at both layers of the lamina.
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http://dx.doi.org/10.1177/0194599814544673DOI Listing
October 2014

Voice disorders in teachers. A review.

J Voice 2014 Nov 11;28(6):716-24. Epub 2014 Jun 11.

Discipline Otolaryngology, Botucatu Medical School, UNESP-Univ Estadual Paulista, Botucatu, São Paulo, Brazil.

Introduction: Voice disorders are very prevalent among teachers and consequences are serious. Although the literature is extensive, there are differences in the concepts and methodology related to voice problems; most studies are restricted to analyzing the responses of teachers to questionnaires and only a few studies include vocal assessments and videolaryngoscopic examinations to obtain a definitive diagnosis.

Objective: To review demographic studies related to vocal disorders in teachers to analyze the diverse methodologies, the prevalence rates pointed out by the authors, the main risk factors, the most prevalent laryngeal lesions, and the repercussions of dysphonias on professional activities.

Materials And Methods: The available literature (from 1997 to 2013) was narratively reviewed based on Medline, PubMed, Lilacs, SciELO, and Cochrane library databases. Excluded were articles that specifically analyzed treatment modalities and those that did not make their abstracts available in those databases. The keywords included were teacher, dysphonia, voice disorders, professional voice.
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http://dx.doi.org/10.1016/j.jvoice.2014.02.008DOI Listing
November 2014

Reducing accidents related to excessive alcohol intake? A retrospective study of polytraumatized patients undergoing surgery at a Brazilian University Hospital.

Rev Col Bras Cir 2013 Nov-Dec;40(6):438-42

Objective: To assess whether the Brazilian Driving Dry Law reached its goal after the three years following its enactment.

Methods: We conducted a retrospective study of patients with craniofacial fractures who underwent surgery at a university hospital in two periods: before the Law (2005 to 2008) and after the Law (2008 to 2011).

Results: 265 patients (220 men and 45 women) were operated on during this period, 149 (56%) before and 116 (44%) after the Law, which indicates a reduction in the number of traumatisms (p=0.04). The age range between 19 and 40 years predominated in both periods. The main causes of traumas were car accidents, physical aggression and falls. Alcohol abuse was identified in 15.4% patients before and 19% patients after the enactment. The jaw and the maxillo-zygomatic complex were the most affected bones.

Conclusion: The drop in the number of polytraumatized patients operated on at this institution in the three years following the Driving Dry Law was 22%, which is below the expected and desired percentage. These results must be compared to those of different services offering the same attendance type in order to compile data and enlarge statistics. The low index of reduction in the number of traumatisms and the report of alcohol abuse by several patients at the moment of trauma, even after the law, evidence the need of adopting stricter measures to control and punish violators.
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http://dx.doi.org/10.1590/s0100-69912013000600003DOI Listing
April 2015

Scanning electron microscopy of the tongue, pharynx, and larynx of rats exposed to cigarette smoke.

J Voice 2014 May 8;28(3):287-90. Epub 2013 Dec 8.

Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Botucatu Medical School, São Paulo State University, Botucatu, São Paulo, Brazil UNESP.

Objective: To examine, by using scanning electron microscopy, the surface of the tongue, pharynx, and larynx of animals exposed to tobacco.

Study Design: Experimental study.

Methods: Twenty rats were allocated to two groups: group I, control group: 10 rats not exposed to any inhaling pollutant and group II, tobacco group: 10 rats exposed to smoke from 10 cigarettes twice a day for 260 days. Animals of both groups had no restriction of food or water. After those 260 days, their aerodigestive segment was removed, and fragments of their tongue, hypopharynx, and right vocal fold were immersed in 2.5% glutaraldehyde and prepared for scanning electron microscopy.

Results: The filiform tongue papillae of the tobacco group were irregularly displayed, flattened, and adhered to each other. The hypopharynx mucosa was highly irregular, thickened, rough and had increased superficial peeling. The mucosa of the vocal folds had deep furrows surrounding the cells. These alterations were not identified for the control group.

Conclusion: Several changes were recorded for the tongue, pharynx, and larynx of tobacco group animals, confirming the harmful effects of smoking to the respiratory and digestive epithelium.
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http://dx.doi.org/10.1016/j.jvoice.2013.09.006DOI Listing
May 2014

Aging voice: presbyphonia.

Aging Clin Exp Res 2014 Feb 26;26(1):1-5. Epub 2013 Sep 26.

Department of Otorhinolaryngology, Botucatu Medical School, São Paulo State University, Botucatu, São Paulo, Brazil,

Presbyphonia is a physiological process of aging voice that includes morphological changes in the coverage mucosa, muscle, and cartilage. We revised the morphological, endoscopic, and vocal acoustic changes that occur in presbyphonia and discussed some treatments proposed to minimize glottal incompetence and improve vocal performance of the elderly.
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http://dx.doi.org/10.1007/s40520-013-0143-5DOI Listing
February 2014

Clinical practice: vocal nodules in dysphonic children.

Eur J Pediatr 2013 Sep 31;172(9):1161-5. Epub 2013 May 31.

Department of Otorhinolaryngology, São Paulo State University, Botucatu, São Paulo, Brazil.

Common among children, vocal symptoms are a cause of concern for parents who seek elucidation of their diagnosis and treatment. Vocal nodules are the major cause of dysphonias in children and are related to vocal abuse. We conducted a literature review considering clinical, physiopathological, epidemiological, and histological aspects of vocal nodules, as well as diagnostic methods, highlighting the main studies addressing this issue. The controversial points of treatments were also discussed.
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http://dx.doi.org/10.1007/s00431-013-2048-xDOI Listing
September 2013

Tonsilar metastases of melanoma in an older person.

Age Ageing 2013 Jul 19;42(4):545-6. Epub 2013 Mar 19.

Opthalmology, Otorhinolaryngology and Head and Neck Surgery, Faculdade de Medicina de Botucatu, Botucatu Medical School, São Paulo State University, Distrito de Rubião Junior s/n, Botucatu, São Paulo, Brazil.

We presented a rare case of metastasis of melanoma in palatine tonsils alerting healthcare professionals to this diagnose in black oral lesions.
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http://dx.doi.org/10.1093/ageing/aft035DOI Listing
July 2013

Comparative study of the behavior of p53 immunoexpression in smoking associated lesions: Reinke's edema and laryngeal carcinoma.

Inhal Toxicol 2013 Jan;25(1):17-20

Botucatu Medical School, UNESP, Sao Paulo, Brazil.

Objective: To assess the behavior of the immunoexpression of protein p53 in Reinke's edema and laryngeal squamous cell carcinoma.

Study Design: retrospective.

Methods: we recovered the histological paraffin blocks of patients who were subjected to Reinke's edema and laryngeal squamous cell carcinoma surgery in 2000-2011. The paraffin blocks were cut into 3-µm sections; the specimens were prepared in silanized slides (one slide for each paraffin block) and subjected to immunohistochemical reaction according to the Avidin Biotin Peroxidase method. Monoclonal primary anti-p53 antibodies were used at 1:50 dilution. Slides were examined under a light microscope at different magnitudes and results were interpreted based on the degree of brown staining in the nuclei of epithelial cells and in the extent of the fragment by using a semi-quantitative score from 0 to 3.

Results: 67 slides of Reinke's edema and 60 slides of laryngeal squamous cell carcinoma were included. Scores 2 and 3 for staining of the nuclei of epithelial cells were recorded for 46 slides of Reinke's edema (68.65%) and for 57 slides of laryngeal squamous cell carcinoma (95%). As to the extent of the fragment, scores 2 and 3 were recorded for 74% slides of Reinke's edema and for 95% slides of carcinomas.

Conclusion: the positive immunoexpression for protein p53, positive in 95% carcinomas and 74% Reinke's edemas, makes us aware of the possible preneoplastic condition of the latter lesion. Further studies are needed to identify and reveal the genetic changes that lead to these results.
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http://dx.doi.org/10.3109/08958378.2012.751142DOI Listing
January 2013

Laryngeal and voice disorders in patients with gastroesophageal symptoms. Correlation with pH-monitoring.

Acta Cir Bras 2012 Nov;27(11):821-8

Division of Otolaryngology, Department of Ophthalmology, Otolaryngology, Head and Neck Surgery, FMB, UNESP, Botucatu-SP, Brazil.

Purpose: To investigate laryngeal and voice disorders in patients with gastroesophageal symptoms and their correlation with pH-monitoring.

Methods: A prospective study was carried out in patients attended at the Voice Disorder Outpatient Clinics of Botucatu Medical School in a five-year period and had vocal and gastroesophagic symptoms. Patients underwent videolaryngoscopy, auditory-perceptual vocal analyses, computerized acoustic vocal analysis and dual probe pH-monitoring for 24 hours.

Results: Fifty-seven patients were included (aged between 21 and 65 years; 45 women and 12 men), 18 had normal (31.6%) and 39 had abnormal pH-monitoring results (68.4%). Videolaryngoscopy recorded several laryngeal lesions for both patients with normal and abnormal pH-monitoring, but mostly for the latter group, highlighting posterior pachyderma. Auditory-perceptual vocal assessments identified vocal changes of several intensities for both groups but especially for patients with abnormal pH-monitoring results. All acoustic parameters, except f0, were abnormal for both groups, compared to the control population.

Conclusion: Acoustic and perceptual vocal changes and laryngeal lesions were recorded for both patients with normal pH-monitoring results and patients with abnormal pH-monitoring results, evidencing the importance of clinical history and videolaryngoscopic findings for diagnosing acid laryngitis.
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http://dx.doi.org/10.1590/s0102-86502012001100013DOI Listing
November 2012

Histological and immunohistochemical study of the expression of p53 and ki-67 proteins in the mucosa of the tongue, pharynx and larynx of rats exposed to cigarette smoke.

Inhal Toxicol 2012 Sep;24(11):723-31

Department of Ophthalmology, Otorhinolaryngology, Head and Neck Surgery, Student of Botucatu Medical School, São Paulo State University- UNESP, Botucatu, Brazil.

Introduction: Head and neck cancers are linked to smoking. The most affected sites are the oral cavity, pharynx and larynx. Experimental studies show epithelial lesions caused by cigarette smoke.

Objectives: To investigate in rats the effects of acute cigarette smoke exposure on the mucosa of the tongue, pharynx and larynx.

Material And Method: Wistar rats were allocated into two groups of 20 animals: CG (control) receiving food and water ad libitum and TG (Tobacco) exposed to the smoke of 40 cigarettes/day for 60 days. Biopsy of their tongues, pharynxes and larynxes were subjected to histopathological, histomorphometric and immunohistochemical studies of protein p53 and ki-67.

Result: The histological analysis of tongue from the Tobacco group revealed epithelial hyperplasia (90%), basal cell hyperplasia (95%) and mild to moderate dysplasia (85%). In pharynx showed basal cell hyperplasia (85%), dysplasia (25%) and vascular congestion (95%). In larynx showed basal cell hyperplasia (70%), epithelial hyperplasia (55%), congestion (100%) and inflammatory infiltrate (25%). Morphometric analysis revealed that keratin layer thickness was greater in the tobacco group. P53 immunoexpression was negative in both groups. Ki-67 immunoexpression was positive in basal cell nuclei but in parabasal cell nuclei it was positive only in the Tobacco group.

Conclusions: The exposure of animals to cigarette smoke for 60 days resulted in benign lesions. The duration of exposure was not enough to cause the development cancer, as confirmed by the negative expression of p53 protein in all slides examined. Analysis of ki-67 expression showed intense epithelial proliferation in response to damage.
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http://dx.doi.org/10.3109/08958378.2012.715317DOI Listing
September 2012
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