[The simultaneous appearance of three uncommon tumours]. / Synchrones Auftreten dreier seltener Tumoren.

A 70-year-old woman presented with nasal obstruction and pain projecting onto the left cheek. The face seemed asymmetric including exophthalmus on the right side. Nasal endoscopic inspection revealed a sarcomatous tumor located on the middle turbinate. The CT showed that the tumor filled the left maxillary sinus completely and had eroded the maxillary bone. In addition, a round, sharply defined intraorbital neoplasm on the right side was identified in the contrast-enhanced MRI. Histological examination of the extirpated intraorbital tumour showed a neurilemmoma. A tissue biopsy of the intranasal tumour falsely suggested an intestinal adenocarcinoma. Multiple neoplasms suspicious of disseminated lung metastases were detected in the CT of the thorax. One round lesion removed by thoracoscopy revealed a carcinoid. The intranasal tumour was excised completely and the histology proved beyond doubt an inverted papilloma.

[Tonsillectomy and tonsillotomy: ENT surgeon and pediatric viewpoints]. / Tonsillektomie und Tonsillotomie: HNO-ärztliche und pädiatrische Sicht.

Tonsillotomy and tonsillectomy are most frequently performed interventions during childhood. There is a need for a critical assessment of indication by using selected criteria. The collaboration of pediatricians and ENT surgeons is essential. Tonsillotomy in children < 6 years of age is associated with lower rates of postoperative bleeding.

[Measurement of quality of life following stapes surgery]. / Lebensqualitätbewertung nach stapesoperationen.

BACKGROUND: The objectives of this study were to compare a German version of the Glasgow Benefit Inventory (GBI) with the original English version and to describe quality of life following stapes surgery. PATIENTS AND METHODS: Audiometry and a questionnaire on handicap in various listening situations were used to assess 36 patients with otosclerosis before and 6 months after stapes surgery. The GBI was used to estimate the change in quality of life following surgery. RESULTS: Postoperative air-bone gap closure was <10 dB in 71% of patients. The postoperative air conduction threshold was <30 dB in 48% of patients. Using the GBI, the mean benefit score was 28 and the general benefit score 42. The social support and physical health scores were both zero. Where the postoperative improvement in air conduction was >15 dB, a significant reduction in handicap in everyday life, watching TV, listening to the radio and making telephone calls was seen. CONCLUSIONS: The German version of the GBI showed an improvement in quality of life in various everyday situations following stapes surgery.

Recurrent neck abscess due to a bronchogenic cyst in an adult.

BACKGROUND: Neck abscesses can originate from congenital cervical cysts. Cervical cysts of bronchogenic origin are rare and often asymptomatic. Common symptoms of bronchogenic cysts are stridor, dyspnoea and dysphagia. The reported patient represents the second published case of a bronchogenic cyst causing a neck abscess in an adult. CASE REPORT: We report a case of a cervical bronchogenic cyst presenting as a recurrent supraclavicular abscess in a middle-aged woman. During extirpation, a fistula was demonstrated to the right upper lobe of the lung, suspected because the cyst inflated synchronously with respiration. DISCUSSION: The symptoms of bronchogenic cysts are due to the effects of compression or fistulas. In the majority of these cysts, a thorough investigation involving history, examination and radiological imaging does not clearly demonstrate a fistula. Therefore, extirpation is both diagnostic and therapeutic. CONCLUSION: A bronchogenic cyst is a very rare cause of a recurrent deep neck abscess. Total extirpation is the treatment of choice.

Salvage surgery after induction chemotherapy with paclitaxel/cisplatin and primary radiotherapy for advanced laryngeal and hypopharyngeal carcinomas.

Induction chemotherapy followed by primary radiotherapy in responders is considered an alternative to surgery for advanced cancer of the larynx and hypopharynx (LHC). Comparison of therapeutic approaches is challenging and must respect oncological and functional outcome as well as quality of life during and after treatment. One aspect of primary radiochemotherapy is the option of salvage surgery in case of residual tumor. The outcome after salvage surgery following new organ-preserving strategies has to be examined. All patients undergoing induction chemotherapy with paclitaxel and cisplatin followed by radiotherapy from 01/96 to 07/05 were included. Salvage surgery was performed either for local recurrence or suspected persistent nodal disease. Complete tumor removal, perioperative morbidity, and overall survival were analyzed in a retrospective study. 28 out of 134 patients underwent salvage surgery after primary treatment with induction chemotherapy and radiotherapy for advanced LHC. 15 patients had laryngectomy (LE) with neck dissection (ND), while 1 patient had lasersurgical partial laryngeal resection with ND for local recurrences. Twelve patients had salvage ND for suspicion of persistent lymph node metastases. 73% of LE patients had major postoperative problems such as pharyngocutaneous fistulas. In 56% of the cases, tumor removal turned out to be microscopically incomplete. Eight out of 12 patients who underwent salvage ND because of suspicious lymph nodes (66%) were free of vital tumor. When metastatic disease was present in the neck (4/12), recurrences occurred in 75% during postoperative follow-up. Only 2 out of 20 patients undergoing surgery for histologically proven recurrence after radiochemotherapy (10%) are actually tumor-free and alive after a mean observation time of 43.9 months. Salvage surgery for local recurrence is associated with high morbidity and poor oncological and functional outcome. ND for suspicious persistent nodal disease after radiochemotherapy can be an over-treatment. In our patients, it was burdened with cervical recurrences and distant metastases in presence of histologically confirmed lymph node metastases. In the light of our results, unfavourable outcome after salvage surgery must be pointed out when initially informing patients about different therapeutic options for advanced LHC.

[Sentinel node mapping in head and neck squamous cell carcinoma]. / Sentinel-Node-Markierung bei Plattenepithelkarzinomen des Kopfes und Halses.

BACKGROUND: Commonly used staging procedures often cannot predict the absence of lymphatic micro- metastases in squamous cell carcinoma (SCC) of the head and neck. Therefore in many cases an elective neck dissection (ND) is necessary. In the surgical therapy of melanoma or breast cancer the presence of metastases can be evaluated securely by identification and examination of the sentinel lymph node (SLN). The type of surgical procedure is usually chosen in regard to the histopathological result. The present study evaluates the applicability of this concept for SCC of the head and neck. METHODS: Radioactive labeled micro-albumin particles were injected preoperatively around the tumor in 38 patients without proven metastases. Following the excision of the primary tumor the sentinel lymph node/s were detected and dissected and ND was completed. Histological examination of the tissue was performed to evaluate whether the SLN reflected the lymphatic status. RESULTS: In two cases (5.1 %) no SLN were detected. ND was completed in 32 cases. In nine cases (28.1 %) the SLN were infiltrated by the primary tumor. In 22 cases (68.8 %) SLN and ND revealed a N(0) stage. In one case (3.1 %) we could not identify a metastasis because of the anatomical closeness of the SLN to the primary. The negative predictive value was 96 %. CONCLUSION: Predictive value regarding metastases to the neck was higher with the detection of SLN than with conventional staging procedures. Whether the detection of a tumor-free SLN is an indication not to perform an elective neck dissection is a matter of discussion, especially under the aspect of the effective reduction of postoperative morbidity.

[Injuries of the head and neck in suicidal intention]. / Verletzungen des Kopfes und des Halses in suizidaler Absicht.

BACKGROUND: Injuries of the head and neck with suicidal intention might create serious situations that require rapid and interdisciplinary treatment. METHODS AND PATIENTS: Twenty-seven patients with suicidal head and neck injuries were treated at the Department of oto-rhino-laryngology, head and neck surgery, University of Wurzburg/Germany, between 1991 and 2002. The medical histories were analyzed retrospectively. RESULTS: Twenty-three of them were male, 4 female. Mean age at time of attempted suicidal was 48 years (18 - 90). One patient was already treated for a psychiatric disorder. None of the patients had a suicidal attempt in the history. Nine patients suffered from a pharynx or larynx trauma after strangulation. Four out of seven patients with cutting or stabbing injuries showed a perforation of the upper airways. Nine patients had gunshot traumas, one of them with perforation of the pharynx. Thirteen patients underwent immediate endoscopy under general anaesthesia followed by a neck exploration in 3 patients. Six patients received a temporary tracheotomy. All patients were considered suicidal for the duration of stay in the ENT-department resulting in a permanent supervision. All patients were transferred to a psychiatric unit as soon as possible for further treatment. A statistically significant accumulation was observed during the last third of a year. Over the period of 11 years, suicidal injuries of the head and neck tend to occur more frequently. CONCLUSIONS: The presented study emphasizes the need of immediate surgical and intensive care treatment of patients with head and neck injuries due to suicide attempts as well as an adequate psychiatric supervision during as well as after the surgical treatment.

Approaches to preserve larynx function in locally advanced laryngeal and hypopharyngeal cancer.

Randomized controlled studies have shown that preservation of the larynx function in patients with advanced resectable laryngeal and hypopharyngeal cancer is possible without compromising survival compared to total laryngectomy (TL). Options for preserving the larynx include function-sparing surgery, radiotherapy alone, induction chemotherapy followed by radiotherapy of responders, and concomitant radiochemotherapy. The current data suggest that induction chemotherapy followed by radiotherapy of responders is an acceptable alternative to TL for patients desiring larynx preservation. Concomitant radiochemotherapy (platinum/5-FU) leads to superior local control and larynx preservation rates compared to induction chemotherapy followed by radiation. The optimal treatment sequence for newer cytotoxic agents is, however, unclear. Such cytotoxic agents and more effective fractionation regimens as well as more advanced surgical techniques are currently evaluated. Predictive tests to successfully stratify patients for the optimal treatment option and more effective systemic therapy are needed to improve therapeutic possibilities and survival.

[Diagnostic impact of multiplanar reformations in multi-slice CT of laryngeal and hypopharyngeal carcinomas]. / Diagnostischer Nutzen multiplanarer Reformationen bei der Mehrschicht-CT von Larynx- und Hypopharynxkarzinomen.

PURPOSE: Assessment of the diagnostic value of multiplanar reformations (MPR) in multi-slice computed tomography (MSCT) by comparing relevant anatomic structures of the larynx and hypopharynx. MATERIALS AND METHODS: MSCT of the neck was performed in 69 consecutive patients (including 30 laryngeal and 12 hypopharyngeal carcinomas). From a 4 x 1.0 mm collimation data set, 3.0-mm and 1.25-mm axial slices as well as 3-mm coronal and sagittal slices were reconstructed. Using the histological examination as gold standard, sensitivity and specificity regarding tumor infiltration for all relevant anatomical structures of the larynx and the hypopharynx were determined for each reconstruction and compared with the McNemar test. Moreover, 42 patients with laryngeal and/or hypopharyngeal carcinoma were subjectively evaluated to determine whether the respective reconstructions enables a better topographical visualization of the tumor in relation to surrounding structures and, furthermore, whether this has an influence on the therapeutical strategy (operation versus radiation therapy, type of operation, surgical approach). RESULTS: Sensitivities and specificities were not significantly different between the reconstructions. However, coronal and sagittal MPR provided a better topographical visualization of the tumor in 14 of 42 (33 %) of the patients, and influenced the therapeutical strategy in 8 of 42 (19 %) of the patients. A lowered signal-to-noise ratio impeded the evaluation of the relatively thin 1.25-mm axial slices in more than 23 % of the cases. CONCLUSION: Besides the 3-mm axial slices, coronal and sagittal MPR can improve the topographical visualization of laryngopharyngeal tumors and are recommended for preoperative MSCT of laryngeal and/or hypopharyngeal carcinomas. Additionally reconstructed 1.25-mm axial slices can be discarded since they do not hold a higher value compared to 3-mm axial reconstructions.

[Prognostic value of pretreatment CT regarding local control in oropharyngeal cancer after primary surgical resection]. / Computertomographische Vorhersagbarkeit Lokaler Rezidive nach primär operativer Resektion von Oropharynxkarzinomen.

PURPOSE: To evaluate the prognostic implication of tumor infiltration and volume in primarily operated oropharyngeal carcinomas. MATERIAL AND METHODS: In 80 patients with oropharyngeal squamous cell carcinomas (pT 1 = 22, pT 2 = 30, pT 3 = 19 and pT 4 = 9), the tumor volume was measured by pretreatment CT and the extent of tumor infiltration determined by postoperative histologic examination. All patients were followed clinically for local tumor recurrence for at least two years after therapy. The statistical analysis consisted of chi 2 and U tests. RESULTS: The local control rate was 79 % (63/80). Of all evaluated anatomic structures, only midline crossing correlated significantly with local recurrence (p = 0.06). No correlation of tumor volume (p = 0.19) or T stage (p = 0.60) with the local recurrence rate was found. CONCLUSION: After primary surgery, oropharyngeal carcinomas with midline crossing have an increased risk of local recurrence, whereas the tumor volume only has a minor impact on the recurrence rate. This is in contrast to laryngeal or hypopharyngeal carcinomas.

[Identification and surgical anatomy of the external branch of the superior laryngeal nerve]. / Der Ramus externus des Nervus laryngeus superior (RELS): Ein Stiefkind in der Chirurgie der Schilddrüse.

Injury to the external branch of the superior laryngeal nerve (EBSLN) during thyroid surgery can cause serious consequences for patients who depend on control of pitch and a clear and forceful voice, like singers or professional speakers. We used the Neurosign 100(R) nerve monitor to identify 157 nerves in 108 patients undergoing thyroid surgery. The EBSLN was successfully identified in 98.7 % of cases. The recording electrode could be placed either into the cricothyroid muscle or the vocal cord. The latter position proved superior if the recurrent laryngeal nerve had to be identified as well. 16 percent of the nerves crossed the branches of the superior thyroid artery at or below the upper pole of the gland, posing a "high risk" for intraoperative lesions. Our data confirm the results of smaller studies reporting this type of nerve course in 12 % to 14 % of patients. The present findings show a significant number of EBSLN to be in danger of injury when the superior thyroid artery is ligated during thyroid surgery. Neuromonitoring proofed to be a reliable method to identify the nerve, which is an important element in concepts to prevent its injury.

[Diagnosis, treatment and results of malignant skull base tumours]. / Diagnostik, Therapie und Ergebnisse in der Behandlung maligner Schädelbasistumoren1.

BACKGROUND: Malignant tumours of the cranial base are rare and present usually in advanced tumour stage due to the lack of early clinical symptoms. PATIENTS AND METHODS: Sixty patients with malignant tumours infiltrating the skull base were treated at the Department of Otorhinolaryngology Head and Neck Surgery, University of Würzburg between 1987 and 1999. Most of the tumours (n = 51) originated from the nose or paranasal sinuses, the epipharynx, the outer ear canal or the middle ear. Seven tumours were malignant brain tumours infiltrating the bony structures of the skull base or originated from the cranial base itself. Two patients suffered from metastases of an adenocarcinoma of the prostata. The histological diagnosis was confirmed in 53 patients preoperatively and in seven patients during tumour resection. Squamous cell carcinoma (n = 24), adenocarcinoma (n = 10) and sarcoma (n = 7) were the most common histologies found. RESULTS: A radical en bloc resection of the tumour was only possible in 26 out of 60 cases. A surgical tumour reduction with postoperative radiation therapy was performed in seven patients as a palliative approach. Eight patients underwent a combined radio- and chemotherapy according to the histological diagnosis. Primary radiotherapy was the treatment of choice in eleven patients, where the tumours were located in the central area of the cranial base. Palliative radiotherapy or solely medical pain control were applied to eight patients who presented either with distant metastases or an advanced tumour growth. The mean postoperative survival following radical surgery was 48 months and after primary radiotherapy 27 months. DISCUSSION: A statistical analysis of the results is not applicable due to the great variety of the disease concerning the histological diagnosis, the tumour size and the location as well as the small number of patients.

[Carcinoma of the external ear canal and middle ear as interdisciplinary challenge for ear surgery and radiotherapy]. / Das Karzinom des äusseren Gehörgangs und des Mittelohres als interdisziplinäre Herausforderung für Otochirurgie und Strahlentherapie.

BACKGROUND: Carcinoma of the external auditory canal are tumours considered to have a poor prognosis. Improvement of the survival rate by surgical means alone is not possible. Individual therapy modalities as a result of an interdisciplinary approach between otosurgeon and radiotherapist are necessary. PATIENTS AND METHODS: A series of 30 patients (3 patients pretreated at other institutions) with carcinoma of the external auditory canal and middle ear treated between 1978 and 1997 in our institutions was analysed with particular reference to tumour size and its relation to surrounding tissues, patterns of neck node involvement, surgical procedures, and radiation techniques. Clinical endpoints were freedom from local failure, overall survival, disease-free survival. The mean follow-up was 4.7 years (range: 0.1 to 18.8 years), median 3 years. RESULTS: Treatment by surgery and radiotherapy resulted in an overall 5-year survival rate of 51%. According to Pittsburgh classification the 5-year survival rate for early disease (T1- and T2-tumours) was 89%, for stage III 67% and for stage IV 39%. Most important prognostic factors were dural infiltration (all patients with dural invasion died within 2.2 years) and the infiltration of surgical margins (the 5-year survival rate of patients with complete tumour resection was 100%, but 54% in patients with tumour beyond surgical margins). 192-iridium HDR afterloading brachytherapy based on 3D CT-treatment planning is an effective tool in the management of local recurrences following surgery and a full course of external beam radiotherapy. CONCLUSIONS: Surgical resection followed by radiotherapy adapted to the stage of disease and grade of resection is the preferred treatment of cancer of the external auditory canal and middle ear.

Up-regulation of matrix metalloprotease-9 in middle ear cholesteatoma--correlations with growth factor expression in vivo?

The role of matrix metalloproteases and their regulation in the pathology of middle ear cholesteatoma is still unclear. Recently we have demonstrated that incubation of keratinocytes with cholesteatoma debris and granulation tissue extracts causes induction of gelatinase B (matrix metalloproteinase-9, MMP-9) secretion in vitro. Antibodies against a variety of growth factors revealed some inhibitory effect on MMP-9 induction, caused by debris or granulation tissue extracts. In order to investigate the coherence of growth factor expression and matrix metalloproteinase activity in vivo in middle ear cholesteatoma, we performed quantitative gelatin zymographic analysis with tissue homogenates of 37 cholesteatoma and nine external ear canal skin (EACS) samples. Furthermore we quantified levels of the cytokines IL-1alpha, IL-1beta, TNF-alpha, TGF-beta and EGF present in tissue extracts, using enzyme-linked immunosorbent assays (ELISA), and correlated cytokine concentrations with gelatinolytic activities. Zymographic analysis revealed a highly heterogeneous expression of gelatinase A and B in cholesteatoma specimens. As shown previously, MMP-9, but not MMP-2, was increased in cholesteatoma when compared to EACS samples. ELISA studies revealed a significantly elevated IL-1alpha level in cholesteatoma. Regression analysis involving gelatinolytic activity and cytokine concentrations in tissue homogenates showed no statistically significant correlation between expression of gelatinases and the cytokines IL1-alpha, IL1-beta, TNF-alpha, TGF-beta or EGF. The discrepancy between in vitro observations and the situation in vivo is discussed critically.

Induction of matrix metalloproteinases in keratinocytes by cholesteatoma debris and granulation tissue extracts.

Although it is generally accepted that destruction and remodeling of temporal bone associated with middle ear cholesteatoma is mainly caused by the action of osteoclasts, it has been shown that neutral collagenases also play a role in predigesting the osteoid layer and exposing the mineralized bone to osteoclastic activity. Here we show that gelatinase B (matrix metalloproteinase-9) is over-expressed in cholesteatoma compared to external ear canal skin (EACS). Expression of MMP-9 in cholesteatoma mainly occurs in suprabasal layers, and more rarely in basal layers of cholesteatoma epithelium, as well as in inflammatory cells of the perimatrix. We further analyzed the influence of cholesteatoma debris, cholesteatoma granulation tissue, and cholesteatoma components such as keratin, cholesterol and bacterial endotoxin on the expression of MMPs in EACS keratinocytes. We show that cholesteatoma debris and granulation tissue extract both induced the secretion of MMP-9 by EACS keratinocytes, while keratin. bacterial lipopolysaccharide (LPS) or cholesterol did not show any effect. We further performed co-incubation and immunoprecipitation experiments using neutralizing interleukin-1alpha, EGF, TGF-beta, TGF-alpha, interleukin-6 and TNF-alpha antibodies. Inhibition of MMP-9 up-regulation by debris or granulation tissue extract could be revealed with diverse cytokine antibodies. The results are discussed with regard to previously published studies.

[Second primary carcinomas in the upper aerodigestive tract in different locations and age groups]. / Das Auftreten von Zweitkarzinomen im oberen Aerodigestivtrakt bei unterschiedlichen Tumorlokalisationen und Altersgruppen.

BACKGROUND: Second primary tumors are of great importance for diagnostics, therapy and prognosis in patients suffering from squamous cell carcinomas of the upper aerodigestive tract. The clinical observation of an increase of second primaries was the reason for analyzing all patients with head and neck cancer treated for a certain period of time at our institution. METHODS: The hospital charts of 576 patients treated for squamous cell carcinoma of the oral cavity, the oropharynx, the hypopharynx and larynx treated from 1993 till 1996 at the Department of Otolaryngology, Head and Neck Surgery of the University of Würzburg were reviewed retrospectively. RESULTS: 10.1% of all patients developed a second primary tumor. The rate was highest for patients with carcinoma of the oral cavity (17.5%), followed by tumors of the hypo- and oropharynx (11.7% and 11.5%) and the larynx (6.4%). Besides the location, younger age was detected as a risk factor for the formation of second malignancies. The latency between first and second primary tumor was 2.9 years in average. 31% of the second primaries were detected synchronous, 39% metachronous. CONCLUSION: The results demonstrate that younger patients and patients with carcinomas of the upper digestive tract need a consequent follow-up. The development of second primaries even years after the first malignoma demonstrates the necessity of lifelong follow-up and oncological care.

Detection of pharyngeal perforation: comparison of aqueous and barium-containing contrast agents.

OBJECTIVE: We sought to assess the value of aqueous and barium-containing contrast agents in the detection of pharyngeal perforation. SUBJECTS AND METHODS: Visual and objective in vitro comparisons of an iodinated aqueous contrast agent, a 50% weight/volume barium suspension, and a 100% weight/volume barium suspension were performed. Moreover, to exclude pharyngeal perforation after surgery, we prospectively examined 109 patients by pharyngography, using the aqueous contrast agent and the 100% weight/volume barium suspension. All patients with a pharyngeal perforation were followed up clinically to exclude complications due to barium application. RESULTS: As opposed to the 100% weight/volume barium suspension, in vitro comparison between the aqueous contrast agent and the 50% weight/volume barium suspension yielded no substantial differences. Seventeen perforations could be detected with the aqueous contrast agent. Although 10 of 17 perforations could be slightly better visualized with the 100% weight/volume barium suspension, two perforations were missed with this agent. Five perforations were equally well detected with both. CONCLUSION: Because of a higher radiopacity, 100% weight/volume barium suspensions may more sharply delineate perforations. However, in contrast to aqueous contrast media, narrow pharyngeal perforations can be missed. Thus, the use of a 100% weight/volume barium suspension does not improve the detection of pharyngeal perforation.