[Integrity of swallowing apparatus-past, present, and future]. / Integrität der Schluckstraße ­ gestern, heute, morgen.

BACKGROUND: Swallowing is one of the most complex movement patterns. The integrity of the epithelial lining is essential. OBJECTIVE: Which surgical techniques were developed at the beginnings of modern surgery and what methods are now available to maintain/reconstitute the integrity of the swallowing apparatus? MATERIALS AND METHODS: This study comprises a selective literature search in early operation manuals and online archives, with incorporation of the authors' own experience. RESULTS: Up until the 1950s, only very limited techniques were available to reconstruct the epithelial lining. Microvascular reanastomosed grafts were the game changer for reconstructive surgery, enabling reconstitution of the swallowing apparatus in primary surgery but also in challenging secondary interventions after insufficient or complicated primary therapy. CONCLUSION: The need for anatomical and functional rehabilitation by reconstructive surgery is as pertinent as ever. Particularly in the oncological context, improved early detection and novel local treatment modalities could minimize treatment-associated damage to swallowing.

[Spontaneous course of traumatic tympanic membrane perforations]. / Spontaner Heilungsverlauf traumatischer Trommelfellperforationen.

BACKGROUND: Traumatic eardrum perforation is a common presentation in otorhinolaryngologic practices and emergency clinics. A consistent management strategy (active intervention vs. watchful waiting) is, however, still lacking. OBJECTIVE: In the following study, the outcome of watchful waiting is analyzed and presented. MATERIALS AND METHODS: A collective of 272 patients presenting at two different specialist ENT practices within days of traumatic tympanic membrane perforation from June 2002 to March 2019 were analyzed. Treatment was non-surgical, with prospective monitoring. Whereas antibiotics were not given at all in one practice, they were given only upon signs of infection in the other practice. The outcome was evaluated retrospectively on the basis of patient files. RESULTS: The collective consisted of 185 males and 87 females. Mean age was 30 years (range: 7 months to 82 years). The perforations were most commonly located in the upper anterior and lower posterior quadrants. According to Griffin grading, the size was grade I in 97%. The three most common causes were impact to the ear, barotrauma, and foreign bodies. Under a watchful waiting regimen, 95% of the patients presenting for follow-up checks showed complete closure. CONCLUSION: Watchful waiting can be assessed as appropriate in traumatic eardrum perforation, provided otorhinolaryngologic follow-up is ensured. An exception is blast injury, which is now much less common in Central Europe, as this is associated with a risk of secondary cholesteatomas. In these rare cases, active treatment with surgical exploration of the middle ear including relining the perforation is indicated.

[Early recognition of cancerous lesions in the mouth and oropharynx: Automated evaluation of hyperspectral image stacks]. / Früherkennung kanzeröser Läsionen in Oropharynx und Mundhöhle: Automatisierte Evaluation hyperspektraler Bildstapel.

BACKGROUND: Early detection of cancerous lesions is still crucial for a patient's prognosis. Although diagnostic access to the oral cavity and oropharynx is comparably easy, the incidence of resulting disease remains high. This is due to the fact that in many cases, malignity is recognized too late on a purely visual basis. Previously, we discussed the application of hyperspectral imaging for early detection of precancerous and cancerous lesions of the larynx. This time, we evaluate the method in the oral cavity and oropharynx. MATERIALS AND METHODS: In 85 patients scheduled for endoscopy, hyperspectral imaging was performed. We used a rigid 0-degree endoscope, a light-adjustable monochromator, and a hyperspectral camera. For evaluation of the method, 3 patients were chosen exemplarily. Training sites from physiological and cancerous tissues were marked. Hyperspectral data from 1 patient were used to train a classifier, which was then used for automatic detection of precancerous and cancerous lesions in another 2 patients. RESULTS: Intraoperative hyperspectral imaging was performed without any problems. Classification showed sensitivities of 61 and 43%, and a specificity of 100%. CONCLUSION: This proof-of-concept study underscores the high potential of hyperspectral imaging for early recognition of cancer in the mouth and oropharynx. Besides a better prognosis for cancer patients, this approach could lead to higher cost efficiency in the health system.

Incidence and localization of abnormal mucosa findings in patients consulting ENT outpatient clinics and data analysis of a cancer registry.

For patients without symptoms and at risk, there is no established early detection program to discover carcinomas of the upper aerodigestive tract in the sense of secondary prevention. Such type of prevention seems even more desirable because the chances for a cure and the quality of life are strongly dependent on the stage of the tumor and the time of the initial diagnosis. Six hundred and eight patients without symptoms but at least one of the self-reported risk factors "smoking", "alcohol consumption" or "reflux" were examined with an endoscope or an optical microscope for pathological findings in the upper aerodigestive tract once a year. In addition, the incidence of malignancies of the upper aerodigestive tract between 2001 and 2010 was determined through the Cancer Registry of Schleswig-Holstein. Tissue samples were taken from 18 of the 608 patients. Eleven patients (1.8%) had a squamous cell carcinoma. Another patient suffered from non-Hodgkin's lymphoma and one from larynx tuberculosis. The ratio of detected malignancies in the oral cavity and the oropharynx on the one hand and the hypopharynx and larynx, which can only be examined by endoscopes, on the other hand were in our cohorts and in our survey according to the cancer registry was 5/6. The above-described methods allow examining risk patients easily and safely. According to current publications, the ratio of the found malignancies exceeds the expected ratio significantly, which presumably was caused by the examination targeting patients at risk. Due to the expanded examination area using optical instruments more than doubles the rate of discoverable malignancies compared to the limitations posed by the examination of directly visible areas of the oral cavity of the oropharynx.

[Soft tissue tumors of the head and neck region]. / Weichteiltumoren des Kopf-Hals-Bereichs.

BACKGROUND: The incidence of soft tissue tumors of the head and neck region is low: 300 and 3 in 100,000 for benign and malignant tumors, respectively. However, sarcomas particularly show a wide variety of different histological subtypes. This article provides an overview of the soft tissue tumors of the head and neck region treated in the authors' institution. MATERIAL AND METHODS: This is a retrospective study including 106 patients treated between 2002 and 2010 due to a soft tissue tumor. Tumor- and patient-specific data were collected (benign/malignant tumor, location, TNM classification, therapy, R classification, grade). RESULTS: In total, 77 benign tumors, 5 of intermediate benign/malignant nature and 24 sarcomas (with 7 different subtypes) were identified. Whereas the benign and intermediate tumors were treated by surgical removal, in 21 of the 24 sarcomas, treatment comprised a multimodal therapy regimen including radio- and/or chemotherapy. CONCLUSION: Whereas benign tumors can be successfully treated by surgical resection, there is no uniform therapy regimen for sarcomas due to the variety of different histological subtypes. Only case-specific interdisciplinary disease management can offer good perspectives for therapeutic success.

[Hyperspectral imaging in head & neck oncology]. / Hyperspectral Imaging in der Kopf-Hals-Onkologie.

Hyperspectral Imaging has long been established in other scientific disciplines than medicine (e. g. earth science) as a means for objective classification of image data information. Some 10 years ago it was first introduced into medicine. Due to its immanent advantages - non-destructive specimen, compatibility with established optical tools (microscope, endoscope), objectivity, and user-independence - several attempts have been made in order to use its potential for the treatment of cancer patients. This publication reviews which methods have been developed for analogue issues in disciplines other than medicine, how these can be transferred into medicine, and what the perspectives are for the traditional innovative field of head-and-neck-oncology.

[Endoscopy of the larynx by hyperspectral imaging]. / Endoskopie des Larynx mit Hyperspectral Imaging.

BACKGROUND: Hyperspectral imaging has been proven to be useful in remote earth sensing, e.g., satellite-based classification of vegetation. After modifying it for in vivo evaluation of the larynx using microscopy, we show its adoption for endoscopes. MATERIALS AND METHODS: In addition to routine microlaryngoscopies under white light inspection, the laryngoscopy was also performed with not only a conventional operation microscope mounted with a tuneable monochromatic light source and a synchronously triggered monochromatic CCD camera (n = 47 patients), but also a similarly modified rigid 0° endoscope (n = 16 patients). Hyperspectral image cubes were obtained between 390 and 680 nm, analyzed using established software tools, and the data using microscope versus endoscope were compared. RESULTS: Under endoscopy, illumination was more even and sterical resolution appeared unchanged at significantly shorter image acquisition times. Hyperspectral classification delineated areas of altered mucosa without further external information irrespective of whether image cubes were generated with microscopy or endoscopy. CONCLUSION: Hyperspectral imaging can be transferred not only to micro(laryngo)scopy but also to endoscopy with rigid optics. This opens the way to a variety of clinically relevant anatomical regions (e.g., upper aerodigestive tract). Its adoption to flexible optics will further broaden this spectrum.

[Quality of life after treatment of head and neck tumors : longitudinal comparison after operation and adjuvant radio(chemo)therapy]. / Lebensqualität nach Therapie von Kopf-Hals-Tumoren : Longitudinaler Vergleich von Operation und adjuvanter Radio(chemo)therapie.

BACKGROUND: Quality of life is extraordinary affected by malignant tumors of the head and neck region as functions of social interaction are disturbed. MATERIALS AND METHODS: The influence of surgical treatment and postoperative radio(chemo)therapy (RCT) on the quality of life was studied in patients with head and neck cancer. Twenty patients treated with curative intention completed the questionnaires EORTC QLQ-C30 and EORTC QLQ-H&N35 at three time points. RESULTS: In most questions, patients reported poorer quality of life after RCT compared to postoperatively. Most of these differences were not significant. However, global quality of life and overall health was significantly worse after RCT as compared to postoperatively. CONCLUSION: Both operation and postoperative RCT, lead to decreased quality of life in patients with a head and neck cancer. In comparison, RCT seems to have a more pronounced effect on the quality of life than operative therapy.

[Treatment results of nasopharyngeal carcinoma in adults]. / Ergebnisse beim Nasopharynxkarzinom im Erwachsenenalter.

BACKGROUND: Nasopharyngeal carcinoma (NPC) is a rare tumor entity in Germany in contrast to endemic countries in Asia or Africa. This retrospective study investigated patient characteristics and prognostic factors with respect to different NPC treatment strategies. PATIENTS AND METHODS: A total of 63 NPC patients treated during the period 1990-2009 at the University Hospital Bonn, Germany, were included. RESULTS: The median age of the patients was 56.4 years, the male:female ratio was 3.2:1, 23.8% were in Union Internationale Contre le Cancer (UICC) stage I/II and 76.2% were in stage III/IV. Most of the carcinomas were WHO type III (57.1%), followed by World Health Organization (WHO) type II (33.3%) and at last WHO type I (9.6%). The 5-year overall survival rate after concomitant chemoradiotherapy (RCT) was 75% and after radiotherapy (RT) 60%. The mortality rate increased by 3.5 times with each increase in T-stage (p ≤ 0.047). The recurrence rate (RR) after RCT was 34% and after RT alone 68% (p ≤ 0.04). Tumor ablation increased the RR significantly (p ≤ 0.047). CONCLUSION: Combined chemotherapy and RT is an effective treatment of NPC disease and clearly superior to RT alone. Tumor ablation before RCT/RT worsens the prognosis and is now obsolete.

[First description of mesenchymal chondrosarcoma of the lateral skull base in a 9-year-old boy]. / Erstbeschreibung eines mesenchymalen Chondrosarkoms der Otobasis bei einem 9-jährigen Knaben.

Mesenchymal chondrosarcoma (MSC) is a very rare sarcoma that is highly malignant with frequent local recurrences and distant metastases leading to a very poor long-term outcome. It differs from classical chondrosarcomas in that it occurs more often in children and commonly in extraskeletal locations. Hardly any evidence-based recommendations for treatment exist. We present the case of a 9-year old boy (pre- and intraoperative findings and histopathological details) who was initially admitted with the diagnosis of a jugular paraganglioma and discuss this case in the light of the recent literature.

[Reduced vocal cord movement and hypopharyngeal tumor]. / Stimmlippenminderbeweglichkeit und ipsilaterale Raumforderung im Hypopharynx.

Chronic lymphocytic leukemia (CLL) is the most common form of leukemia in the Western World. It belongs to the low-grade non-Hodgkin lymphomas and is characterized by clonal reproduction of mature small-cell non-functional B-lymphocytes. CLL affects men somewhat more often than women and the average age at onset is over 50 years. In addition to regional lymph node swelling, typical symptoms include hepatosplenomegaly, leukocytosis and skin disorders such as eczema and pruritus. Manifestations in the oropharynx or hypopharynx are rare but should be kept in mind in the differential diagnosis.

[Prevalence of abnormal mucosal findings in patients in HNO practices]. / Prävalenz auffälliger Schleimhautbefunde bei Patienten in HNO-Praxen.

OBJECTIVE: To date, no secondary prevention program is in place for patients carrying an increased risk for developing head and neck cancer (HNSCC). In terms of successful, long-term curative therapy and increased quality of life, it would be useful to detect such diseases at an early stage. PATIENTS AND METHODS: A total of 370 patients with at least one risk factor such as "smoking", "alcohol", or "reflux disease" and without any symptoms were examined during a 1-year period using standard HNO methods (e. g. endoscopy) for suspicious alterations of the mucosa of the upper aerodigestive tract. RESULTS: In 13 (3.5%) of all 370 cases a biopsy was taken for further diagnosis. Squamous cell carcinoma was found in eight cases, while one further patient was suffering from non-Hodgkin lymphoma. CONCLUSIONS: It is simple and safe to examine patients at risk of developing HNSCC by standard HNO methods. The rate of detected carcinomas is much higher than in former investigations, likely because our survey focused only on patients with specific risk factors.

[Tonsillar lymphangiomatous polyp]. / Lymphangiomatöser Tonsillenpolyp.

Lymphangiomatous polyps are rare benign lesions of the tonsils. We report the case of a female patient presenting with dysphagia of 15 years' standing due to such a lesion. After surgical excision the patient remained free of symptoms and experienced no recurrence (follow-up 17 months). The histology was characterized by epitheliotropism of lymphocytes as well as dilated lymphatic channels, blood vessels and edema. Immunohistochemical staining with D2-40 monoclonal antibody and podoplanin confirmed the diagnosis of lymphangiomatous polyps. We discuss the current literature.

[Cytomics and predictive medicine for oncology]. / Zytomik und prädiktive Medizin in der Onkologie.

One hundred and fifty years after Virchow introduced his fundamental concept of cellular pathology, we now have tools that allow us to unravel the mechanisms of single living cells on a previously unprecedented level of detail. By exploring the molecular cellular phenotype, multiparametric cytometry not only detects specific cellular functions in general but also offers insights into the interaction of single subunits of proteins (e.g., growth factor receptors). Several quantitative and objective techniques allow analysis of single-cell preparations as well as tissue sections to obtain data on different cellular parameters. This opens the way to quantitative and objective histology, which in the future may be possible even without blood or the need to make an incision. To use this huge amount of data for treatment decisions in an individual patient, novel bioinformatic concepts are needed in order to predict the individual course of a disease. The concept of cytomics centers on the cell as the integral unit of all life and explores diseases starting from the cell and going to subcellular units (top-down analysis).

[Slide-based multi-parametric cytometry in ENT. Perspectives for the clinic and research]. / Objektträgerbasierte multiparametrische Zytometrie in der HNO. Perspektiven für Klinik und Forschung.

BACKGROUND: Flow cytometry is the standard method for the multi-parametric analysis of cells. However, for about a decade, an instrument has been available which analyses fluorescing cells immobilised on slides called a laser scanning cytometer (LSC). Its design, according to the principles of slide-based cytometry, promises many advantages, especially in the analysis of minimal sample volumes. METHODS AND PATIENTS: To date, applications for cultured cells and animal models have been established. Its use for clinical purposes, however, remains to be critically evaluated. We analysed a variety of specimens obtained in our clinical routine. RESULTS: First, the instrument's resolution was evaluated using standardised particles. This showed a very good sensitivity across a wide range of fluorescence intensities at various wavelengths. Next, diverse applications for tissue engineering, immunophenotyping, and ENT-oncology were tested. Considering its microanalytical capacities, LSC proved to be a convincing tool for clinical use. Additionally, complex structures such as bi-layers of cultured cells were analysed. CONCLUSION: A broad spectrum of applications in clinical practice and research for the LSC is evident.

[Carcinoma of the mouth and pharynx--better prognosis by an early diagnosis!]. / Mundhöhlen- und Rachenkarzinome durch frühzeitige Diagnose zu besserer Prognose.

Carcinomas of the mouth and pharynx rank sixth of all malignant tumours worldwide. They are responsible for 10% of the newly diagnosed malignant tumours. The median five year survival rate is 50%, depending on tumour localisation and size, but mainly determined by lymph node metastases. Carcinomas of the mouth and pharynx cause symptoms that resemble those of common harmless diseases of the head and neck such as pharyngitis. This can lead to misinterpretation by both, the patient and the doctor. Since the initial delay by the patient is difficult to influence it is very important that the doctor is aware of a possible malignant disease. Persistent common symptoms such as swallowing impairment or hoarseness, mucosal lesions, such as leukoplakia, a persistent cervical lymph node and unresponsiveness to initial treatment, must prompt the doctor to initialise appropriate diagnostic steps (incisional biopsy, e.g.). Only early diagnosis can help to improve the prognosis of patients with carcinomas of the mouth and pharynx.

Eosinophilia in nasal polyposis: its objective quantification and clinical relevance.

BACKGROUND: Eosinophilia within nasal polyps is often taken as a criterion for adjuvant medical treatment postoperatively such as topical steroids. OBJECTIVE: This study was performed in order to validate a new technique for objective quantification of eosinophilia by using laser scanning cytometry (LSC), to compare these results with manual scoring and routine histopathology, and to correlate them with the history of allergy or recurrence. METHODS: LSC was used for semi-automated analysis of single-cell preparations from representative ethmoidal polyps obtained during routine paranasal sinus surgery (n=41). This microscope-based instrument scans the cells after immobilization of cells on a glass slide and after triple staining of cytokeratin, eosinophilic granula, and DNA. The location of each cell is stored with the fluorescence data. Therefore, the morphology of every cell can be documented by re-staining with haemotoxylin and eosin and re-localization on the slide. Subsequently, slides were subjected to manual scoring. The remaining polyps were analysed by routine histopathology. RESULTS: Data from LSC and manual scoring showed good correlation (r=0.81, P<0.001), whereas there were discrepancies with histopathology. Eosinophilia scored by LSC and histopathology was neither correlated with the history of allergy nor with recurrence as determined by Fisher's exact test independent of the definition of eosinophilia (> or =2%, > or =3%, or > or =5% of all cells). CONCLUSION: Scoring eosinophilia by LSC in comparison with histopathology does not contribute to a more reliable basis for adjuvant medical therapy in nasal polyposis. Instead, functional parameters (cytokine production, apoptosis) may serve better.

Analysis of minimal sample volumes from head and neck cancer by laser scanning cytometry.

BACKGROUND: The increasing diversity in therapeutic strategies in head and neck oncology is dependent on the development of equally appropriate diagnostic tools. A growing number of diagnostic procedures is intended to be performed on an out-patient basis. In this context, analyses of hypocellular specimens such as fine-needle aspirate biopsies (FNABs) or swabs are very important: There are minimal side-effects, and they can be analysed within hours. MATERIAL AND METHODS: Laser scanning microscopy (LSC) is a microscope-based method combining the advantages of flow cytometry and image analysis: In addition to the fluorescence data of each individual cell, its morphology can be documented by re-staining with a conventional cytological staining. Any cell can then be re-localised in the microscope for direct observation. FNABs and swabs are incubated in PBS, erythrocytes are lysed, and cells are mounted on slides. After fixation in ethanol, cells are stained for cytokeratin by indirect immunolabelling and for DNA by propidium iodide. Analysis by LSC is performed to determine the ploidy of the epithelial cells. For immunophenotyping of peripheral blood in cancer patients by LSC 20 microl full blood are stained for CD antigens by direct immunolabelling and for DNA by 7-aminoactinomycin D. RESULTS: FNABs and swabs were taken from 150 malignancies of different sites in total; all specimens yielded sufficient cells (>5,000). 30 tumours of the parotid gland were analysed in detail: Out of 9 malignant tumours 8 showed aneuploidy, whereas all 21 benign tumours were diploid. Immunophenotyping in 23 tumour patients showed a significant reduction of lymphocytes in the peripheral blood as compared to healthy individuals. CONCLUSIONS: Further studies have to be performed to validate the analysis of hypocellular specimens by LSC and to determine its role in routine clinical work. Its potential is most evident in tumours that are not accessible for open biopsy such as those of the parotid gland or the larynx.