[Jugular vein thrombosis and Lemierre's syndrome--severe complications of oropharyngeal infections]. / Jugularvenenthrombose und Lemierre-Syndrom--schwerwiegende Komplikationen oropharyngealer Infekte.

BACKGROUND: Acute oral or pharyngeal infections usually heal under adequate therapy within a few days. Therefore severe regionary or systemic complications are not regularly seen. PATIENTS AND METHODS: We report on 3 patients in whom during or after apparent recovery from a pharyngeal or perioral infection a one-sided painful swelling of the neck associated with fever and leucocytosis developed. RESULTS: Color Doppler sonography (CDS) revealed unilateral thrombosis of the internal jugular vein (IJV) in all cases, whereupon we initiated high-dosed parenteral antibiotic therapy and therapeutic heparinisation. Furthermore, we drained detectable abscess formations. Nonetheless, in one patient fever attacks occurred postoperatively, accompanied by septic-embolic lung infiltrates, corresponding to Lemierre's syndrome. In all cases, we achieved clinical recovery and remission of infection. The course was significantly prolonged in the patient with pulmonary involvement and in this patient no reperfusion of the IJV was achieved. CONCLUSIONS: Even today serious complications may occur unexpectedly in presumed everyday oral or pharyngeal infections. CDS is a suitable procedure to disclose a jugular vein thrombosis (JVT) promptly and non-invasively. Parenteral antibiotic therapy for at least 10 days is usually the therapy of choice for JVT; additional full-heparinisation is controversially discussed in the professional literature. Septic pulmonary embolism following pharyngeal infection and JVT, as described by Lemierre, was associated with a high rate of mortality in the pre-antibiotic era, and even today may be fatal in spite of appropriate and maximal therapy.

[Modification of the retrolabyrinthine approach with hearing preservation in CPA tumors]. / Modifizierter retrolabyrinthärer Zugangsweg bei Kleinhirnbrückenwinkeltumoren zum Hörerhalt.

BACKGROUND: In an anatomical study including a CT scan of the cadaver sections by means of a virtual model analysis the option of a modified retrolabyrinthine passage to the cerebellopontine angle (CPA) preserving the Saccus endolymphaticus and the upper petrosus sinus was analysed. METHODS: Due to the individual anatomical variations of the petrosus bone the results showed several limitations with regard to the retrolabyrintine passage to the CPA. The smallest distance between the dura of the posterior fossa and the posterior semicircular canal measured in a high resolution CT was of particular importance as to how much room was available for the surgical manipulation in the retrolabyrinthine space. As the back side angle to the petrosus bone is much flatter in a translabyrinthine approach than in a retrosigmoidal approach the internal auditory canal needed to be controlled by using a 30 degree endoscope. RESULTS: In five patients the translabyrinthine approach was modified by temporarily preserving the labyrinth in an effort to remove the CPA tumors. Based on our clinical experience and on the findings of the anatomical and radiological studies we eventually removed the CPA tumors type B2 or C3 in three patients preserving hearing by using a modified retrolabyrinthine approach.

[Sonography aided computer assisted surgery (SACAS) in orbital surgery]. / Sonographisch unterstützte computerassistierte Chirurgie (SACAS) in der Orbitachirurgie.

BACKGROUND: The application of computer assisted procedures in orbital surgery is made more difficult by the intraoperative tissue shift in intraorbital structures, since this intraoperative dislocation cannot be imaged in preoperative CT/MR datasets. METHODS: After preoperative recording of CT and/or MR datasets in five patients with orbita affected by frontobasal tumors, we used intraoperative sonography by coupling the ultrasound unit to the navigation system. RESULTS: Registration, referencing and calibration of the ultrasound system proceeded without any difficulties. Intraoperatively, the structures of the anterior and middle thirds of the orbita and their tissue shift could be particularly well evaluated sonographically. CONCLUSION: The use of navigated sonography enables repeated intraoperative re-evaluation of preoperative CT/MR datasets. The fusion of intraoperative sonography with preoperative imaging visualizes the tissue shift and facilitates the identification of anatomical structures and the spatial orientation of the surgeon. This appears to allow both increased operative radicality and greater tissue protection. In our opinion, the intraoperative parallel application of a non-calibrated ultrasound system and an only CT/MRT based navigation system cannot fulfill these requirements because of anatomical complexity.

[Posttraumatic amaurosis after complex frontobasal fracture. Differential diagnosis and therapy]. / Posttraumatische Amaurose nach komplexer frontobasaler Fraktur. Differenzialdiagnostische und therapeutische Aspekte.

BACKGROUND: Whether surgical nerve decompression is indicated for the treatment of posttraumatic reduced vision with optic nerve compression in the bony canal has been a subject of controversy for decades. On balance, the recent literature suggests that this procedure is indeed indicated, as a supplement to high-dosed cortisone therapy. The risk of surgery-related side effects is usually rated low in the literature. CASE REPORT: We report on a woman patient in whom craniocerebral trauma involved a fracture of the left optic canal with unilateral loss of vision. In the decompression operation, intraoperative symptoms gave rise to the suspicion of an arteriovenous fistula, which had not been revealed by computer tomography and which was seen as sufficient grounds for discontinuing the procedure. In addition to a carotid artery-sinus cavernosus fistula (CCF Barrow type A), subsequent angiography revealed a dissected aneurysm at the branching of the occluded ophthalmic artery. DISCUSSION AND CONCLUSIONS: In decisions on whether surgical relief of pressure on the optic canal is indicated after trauma-related visual loss, the possibility of secondary lesions near the tip of the orbita and the optic canal must be taken into account. These are not always revealed by computer tomography. The indications should be critically weighed up in each individual case, with additional imaging examinations, such as MR-angiography, CT-angiography, or conventional angiography, performed as needed. The options and indications for imaging are discussed. The procedure can by no means be rated as "minimally invasive", as is postulated by some authors.

[Multidisciplinary management of skull base and craniocervical chordoma]. / Clivuschordome -- multidisziplinäre Fortschritte und prognostische Relevanz.

BACKGROUND: Craniocervical chordomas often only become manifest in an advanced stage. The localisation and locally-destructive growth require a multidisciplinary diagnostic and therapeutic concept early on. The goal of the present study was to present a reproducible strategy for quality assurance. PATIENTS AND METHOD: We retrospectively analysed the hospital records of 10 consecutive patients (4 women and 6 men) whom we had treated during a period of 7 years. RESULTS: The first step in therapy was tumour resection in 9 cases. One patient initially underwent stereotactic radiation. Postoperative radiation was not included a priori, but discussed individually depending on the degree of resection, the patient's age and physical condition. After an average 5 years follow up, 100 % of patients are alive. In all patients, tumour control was achieved. CONCLUSIONS: The prognosis for patients with chordomas of the skull base has improved considerably in recent years. New technologies like intraoperative navigation and improved radiation procedures have contributed to this improvement. The basis for treatment remains, however, the greatest possible surgical exstirpation with minimal surgical morbidity. Special attention should be paid in this connection to the stability of the cervical spine and the craniocervical transition border. In advanced tumour growth, complete resection is often not possible. Proton and heavy-ion radiation are promising new forms of therapy, which can also be applied after conventional radiation has been performed. A directed multidisciplinary procedure guarantees years of survival with good quality of life in many cases.

[Cochlear protection and surgical precision in stapedotomy with Er:YAG laser]. / Cochleaprotektion und chirurgische Präzision bei der Er:YAG-laserchirurgischen Stapedotomie.

BACKGROUND: Using laser in stapedotomy has attracted a lot of attention since the nineties. It aims at minimizing complications due to hand-operated equipment, especially inner ear lesions, and achieving higher precision. We analyzed the clinical effect of Er:YAG laser with the question whether the postulated cochlea protection and foot plate perforation, optimized for better sound conduction, are achieved, compared to conventional stapedotomy. PATIENTS AND METHODS: We evaluated retrospectively audiometrical data including pre- and postoperative bone and air conduction thresholds of 114 consecutive patients, on whom we had performed stapedotomy and had inserted platinum-teflon prostheses. The intervention was done conventionally in 72 cases and in 42 cases with Er:YAG laser. RESULTS: In the lower and middle frequencies, laser technique resulted in a more pronounced improvement of bone conduction thresholds compared to conventional stapedotomy. The improvement of air conduction was more distinct in ears after laser surgery; also, the difference between air and bone conduction was reduced at a higher degree. CONCLUSION: Er:YAG laser in stapedotomy is coupled with cochlea protection, as demonstrated under clinical conditions, and allows higher hearing benefit of air conduction compared to conventional stapedotomy. Our results emphasize the impact of innovative laser technique on stapedotomy.

[Skull base chondrosarcoma. An interdisciplinary challenge]. / Schädelbasischondrosarkome. Eine interdisziplinäre Herausforderung.

BACKGROUND: Chondrosarcoma is a rare differential diagnosis of malignant tumours of the skull base. The prognosis was rated as unfavourable in articles for many years. It has, however, improved considerably in recent years. The objective of this study was to evaluate and current, new optimised treatment strategies. PATIENTS AND METHODS: We retrospectively analysed the case histories and course of four patients whom we treated for chondrosarcoma of the skull base over the past 5 years at the Freiburg Skull Base Centre. RESULTS: Because of initially mild symptoms, the patients first came for examination at an advanced stage of the tumour. All patients underwent surgery, whereby an R0-resection was barely or only questionably present. Three patients underwent radiation therapy postoperatively. All patients are currently tumour free. CONCLUSIONS: Surgical treatment with curative intent is basically the therapy of choice. Due to the usually large size of the tumour and its close relationship to relevant structures, complete resection is, however, not always possible despite advances in surgical procedures. Taking the possibility of modern adjuvant radiotherapeutic procedures into account, an incomplete, function-preserving resection is preferred to a radical and mutilating resection.

[The interesting case -- case no. 67]. / Der interessante Fall Nr. 67.

BACKGROUND: Lipoma of the retropharyngeal space is a rare benign tumour often showing unspecific clinical symtoms. It can grow to an enormous extent causing total obstruction of the upper respiratory tract. Until now its etiology is unknown. With a variety of differential diagnoses, a diagnostic concept is necessary. CASE REPORT: A 41 year old male patient complained about a nondolent swelling of the neck. The radiological diagnostics showed a huge lipoma of the para- and retropharyngeal space with subtotal obstruction of the pharynx. The lipoma was removed completely via transcervical approach. CONCLUSION: Lipoma as differential diagnosis of retropharyngeal tumours always has to be considered. Surgical intervention is recommended. To prevent functional complications resulting from tumour and surgery and to get information about the extent of the lipoma, accurate radiological imaging is mandatory.

[Obliterated cochlea in Cogan's syndrome -- implications for cochlear implant surgery]. / Obliteration der Cochlea beim Cogan-Syndrom -- Bedeutung für die Cochlear-Implant-Chirurgie.

BACKGROUND: Acute, often bilateral deafness in Cogan's syndrome or other autoimmune diseases is caused by autoimmune mediated inflammatory attack on the membranous labyrinth. Auditory rehabilitation in case of bilateral deafness can be achieved by cochlear implant surgery. METHODS: A retrospective analysis of all patients suffering from Cogan's syndrome that had received a cochlear implant, was carried out. RESULTS: 6 of 295 adult patients (2.6 %) that had received a cochlear implant, had become deaf due to Cogan's syndrome. Partial obliteration or ossifikation was encountered in all cases and influenced surgical procedure. In one case a fibrous obliteration of the scala tympani was found 8 weeks after acute onset of complete deafness. CONCLUSIONS: The course of obliteration is unknown. With regard to our results a fibrous obliteration may occur as early as 8 weeks after complete deafness. This has to be considered in counseling of patients. Only early cochlear implant surgery facilitates best possible rehabilitation results.

Imaging procedures in cochlear implant patients--evaluation of different radiological techniques.

The purpose of this study was to evaluate the feasibility and usability of different radiologic methods (single-slice computed tomography (CT), multi-slice CT and rotational tomography (RT)) for assessment of the position of cochlear implant electrodes. Cochlear implants in an isolated human temporal bone and in a complete formalin-fixed cadaver head were examined and the electrode position was determined. Subsequently, the labyrinth bone was isolated out of the cadaver head and histologically examined to compare the results of histology with imaging. Single-slice CT reliably identifies the electrode inside the human cochlea; however, due to the technically based large electrode artifact its position inside the cochlear spaces (e.g. electrode position in scala tympani or scala vestibuli) cannot be detected. Multi-slice CT of the cadaver head also showed artifacts that complicate the assessment of electrode position. Using RT the electrode artifact is small and therefore the electrode position within the cochlear spaces, scala tympani versus scala vestibuli, can be assessed. This technique was also applicable in a complete cadaver head, which is in contrast with former studies. In conclusion, CT allows the identification of electrode arrays inside the human cochlea. Multi-slice CT permits a much more precise depiction of the electrode inside the cochlea. RT alone has minimized electrode artifacts to a high extent and permits the assessment of the electrode position within the scala tympani or scala vestibuli. As RT was performed successfully in a complete cadaver head, further studies for evaluation of the intracochlear electrode position can now be performed in patients.

Imaging procedures in cochlear implant patients - evaluation of different radiological techniques.

The purpose of this study was to evaluate the feasibility and usability of different radiologic methods (single-slice computed tomography (CT), multi-slice CT and rotational tomography (RT)) for assessment of the position of cochlear implant electrodes. Cochlear implants in an isolated human temporal bone and in a complete formalin-fixed cadaver head were examined and the electrode position was determined. Subsequently, the labyrinth bone was isolated out of the cadaver head and histologically examined to compare the results of histology with imaging. Single-slice CT reliably identifies the electrode inside the human cochlea; however, due to the technically based large electrode artifact its position inside the cochlear spaces (e.g. electrode position in scala tympani or scala vestibuli) cannot be detected. Multi-slice CT of the cadaver head also showed artifacts that complicate the assessment of electrode position. Using RT the electrode artifact is small and therefore the electrode position within the cochlear spaces, scala tympani versus scala vestibuli, can be assessed. This technique was also applicable in a complete cadaver head, which is in contrast with former studies. In conclusion, CT allows the identification of electrode arrays inside the human cochlea. Multi-slice CT permits a much more precise depiction of the electrode inside the cochlea. RT alone has minimized electrode artifacts to a high extent and permits the assessment of the electrode position within the scala tympani or scala vestibuli. As RT was performed successfully in a complete cadaver head, further studies for evaluation of the intracochlear electrode position can now be performed in patients.

The Nucleus Contour electrode array: a radiological and histological study.

OBJECTIVES: To evaluate the handling and insertion trauma of the recently developed Nucleus perimodiolar Contour electrode array (Cochlear Ltd., Pty, Lane Cove, New South Wales, Australia) in human temporal bones compared with the Nucleus standard straight electrode array. STUDY DESIGN: E-perimental control group. METHODS: Twenty-nine fresh-frozen bones were implanted with different electrode arrays by an experienced cochlear implant surgeon, and evaluated both radiologically and histologically. RESULTS: Intracochlear insertion of the standard Nucleus straight electrode array was found to be atraumatic, confirming previous findings in the literature. Insertion of the Nucleus Contour electrode array resulted in instances of localized basilar membrane penetration causing the electrode array to move from the scala tympani into the scala vestibuli. However, this trauma did not result in any observable damage to the osseous spiral lamina or the modiolus. Basilar membrane penetration was observed in six of eight cochlear bones when a standard cochleostomy size (approximately 0.8 mm) and site (anterior and superior to the round window) were used. However, when the surgical technique was modified to use a slightly larger cochleostomy ( approximately 1.8 mm) situated closer to the round window and employ a partial stylet withdrawal technique during electrode insertion, the frequency of penetrations was restricted to two of seven bones. This trauma rate is comparable to that observed with other cochlear implants designs. CONCLUSIONS: Following our results, the design of the Nucleus Contour electrode appears to fulfill the safety requirements for an intracochlear electrode array, provided that the surgical insertion technique is modified in the manner outlined.