[Hebephrenia - a viable psychopathological construct?] / Hebephrenie ­ ein brauchbares psychopathologisches Konstrukt?

Ewald Hecker was the first psychiatrist to describe the disease entity of hebephrenia in some detail, focusing mainly on disturbances of affect. Later Emil Kraepelin and Eugen Bleuler saw hebephrenia as a subtype of dementia praecox or schizophrenia. Willy Mayer-Gross and Karl Leonhard characterized hebephrenia with highly differentiated psychopathological descriptions, whereas this construct only played a minor role in the works of Klaus Conrad and Kurt Schneider. The International Classification of Diseases (ICD-10) lists hebephrenia as a subtype of schizophrenia but in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) no subtypes of schizophrenia are mentioned and the concept of hebephrenia is thus lost. Hebephrenia can be seen as an ideal type describing a psychopathological course pattern. This construct can be useful to conceptualize a group of disorders of affect which otherwise escape description, especially since these psychopathological alterations of affect are difficult to operationalize. To have a viable concept of these disorders is relevant for the prognosis and therapy planning. If the concept of hebephrenia is abolished, important psychopathological knowledge might be lost for future generations of psychiatrists.

[Psychiatry as a practical science : Considerations following Wolfgang Wieland (1933-2015)]. / Psychiatrie als praktische Wissenschaft : Überlegungen nach Wolfgang Wieland (1933­2015).

In the light of historical and modern criticism of the discipline of psychiatry and psychotherapy as a medical subspecialty, this paper deals with aspects of the theory of medicine as postulated by the physician and philosopher Wolfgang Wieland. According to his contributions medicine is a practical science aiming at establishing rational action. Central to this model is a diagnosis, which helps to subsume individual cases under general principles from which essential therapeutic options can be derived. Hence, psychiatry and psychotherapy become a medical subspecialty by adopting the basic model of medical reasoning and action as described by Wieland. Nevertheless, the limits of such an approach must be taken into consideration. Especially in a psychiatric and psychotherapeutic context it is of particular importance that even when being guided by general principles the responsibility for the personality of each individual patient should be adequately met. Furthermore, attention should be paid to the limits of the subspecialty of psychiatry and psychotherapy as a medical discipline, which also requires a critical analysis of the concept of psychiatric illness.

[The Concept of Typology in Psychiatry in the Context of Historical Contributions of Max Weber and Karl Jaspers]. / Das Typuskonzept in der Psychiatrie - Überlegungen nach Max Weber und Karl Jaspers.

Against the background of Max Weber's and Karl Jaspers' outstanding historical contributions to the conceptual development of different typologies, the importance of a psychiatric typology is examined. The term "ideal type" was introduced into social science by Weber as an analytical construct to describe and classify cultural phenomena. This concept was adopted for the psychiatric context by Jaspers who proposed to establish a typological system in the field of psychotic disturbances without an organic correlate. He emphasized the importance of the course of psychopathological symptoms for such a typological system. The concept of typology can be regarded as a promising heuristic approach in psychiatry, providing a classification system for complex psychopathological symptoms. Even though several historic typologies exist in psychopathology, their usefulness in the fields of therapy and prognosis needs to be critically assessed. Also, new typologies will have to be developed, taking into account neurobiological knowledge now available.

[Facial nerve schwannoma in the inner auditory canal and geniculate ganglion]. / Schwannome des N. facialis im inneren Gehörgang und am Ganglion geniculi.

BACKGROUND: Schwannoma of the vestibular nerve is the most common tumor found in the inner auditory canal. If a schwannoma of the facial nerve is found unexpectedly during surgery, the original surgical plan may have to be changed. In our series, we describe the symptoms, diagnostic procedures and therapy of this infrequent, benign tumor. In particular, we want to analyse the influence of diagnostic techniques, such as magnetic resonance tomography and electrophysiology, on the diagnosis of these tumors. PATIENTS: Between 1975 and 2001, we diagnosed 17 cases of facial nerve schwannoma in the inner auditory canal or the geniculate ganglion. All patients were treated surgically. In 16 cases, we used the enlarged middle fossa approach and in the remaining patient the translabyrinthine approach was used. RESULTS: In 11 cases, the facial nerve could be saved but in six the nerve had to be rebuilt with a transplant. During the first years of our study, palsy of the facial nerve was a frequent finding. In the later years, a hearing impairment and tinnitus became the most frequent symptoms. CONCLUSIONS: Advances in magnetic resonance imaging have, in many cases, facilitated the differentiation between schwannomas of the facial nerve and the vestibular nerve over the last years. Signal enhancement at the geniculate ganglion is important for the diagnosis of facial nerve schwannoma. In individual cases, we found significant findings using electrophysiological procedures. In three cases, the temporal delay was elongated. Based on these findings, the therapeutic procedures can be discussed together with the patients.

Nasal airway changes after Le Fort I--impaction and advancement: anatomical and functional findings.

Twenty patients were studied prospectively to assess intranasal anatomical changes and functional changes resulting from a one-piece Le Fort I-osteotomy with anterior and superior positioning of the maxilla. Presurgical and 3 months postsurgical rhinological inspection, anterior rhinomanometry and acoustic rhinometry were performed. Interalar width was measured and cephalograms were used to assess maxillary movement. Rhinoscopically, three septal perforations (15%) were noticed. Turbinate enlargement was less common postoperatively. Interalar width increased significantly. These findings correlate with a significant increase in cross-sectional diameter at the Isthmus nasi revealed by acoustic rhinometry 3 months postoperatively. The mean total nasal airflow measured by anterior rhinomanometry was unchanged indicating no increase in resistance despite decreased intranasal dimensions in cases where the impaction is not higher than 5 mm.

Enlarged middle fossa vestibular schwannoma surgery: experience with 735 cases.

OBJECTIVE: To show the clinical outcome in patients with sporadic vestibular schwannoma (VS) operated on by the enlarged middle cranial fossa approach (EMFA). STUDY DESIGN: Retrospective case review. SETTING: A tertiary referral center with four neurotologists experienced in EMFA surgery. PATIENTS: There were 376 women and 359 men, with a mean age of 51.1 years (range, 12-77). INTERVENTION: Enlarged middle cranial fossa approach surgery. MAIN OUTCOME MEASURES: Magnetic resonance imaging and computed tomography scans were used for follow-up and re-evaluation of the operative sites. Facial nerve function and hearing were tested. RESULTS: Overall complete VS removal was achieved in 97.1% of patients. There were two recurrences (0.3%) after microscopically complete tumor removal. Depending on the tumor size, postoperative normal and near-normal facial outcome ranged from 83% to 99% (average, 92%), and hearing at or near the preoperative level (+/-15 dB pure-tone average or +/-15% speech discrimination) was preserved in 60.2%, 48.2%, 23.9%, and 17.6%, respectively. CONCLUSIONS: The EMFA is an excellent low-morbidity approach for VS removal with limited cerebellopontine angle extension (2 cm). Specific advantages of the EMFA are the superior internal auditory canal exposure, resulting in an extremely low tumor recurrence rate; best capability for hearing preservation; and minimal incidence of cerebrospinal fluid leaks. Postoperative facial function outcome compares with that of other surgical approaches. The best results are achieved in subjects with small tumors and good hearing, advocating early diagnosis and treatment.

Extended middle fossa surgery for meningiomas within or at the internal auditory canal.

OBJECTIVE: To show the clinical outcome in patients with meningioma within or at the internal auditory canal (IAC) operated on by the extended middle cranial fossa approach. STUDY DESIGN: Retrospective case review. SETTING: A tertiary referral center. PATIENTS: Twelve patients, 9 women and 3 men, whose ages ranged from 37 to 70 years (mean 57 years). One tumor was entirely intracanalicular, 5 had an intra-extracanalicular growth, 3 were centered at the posterior porus lip, and 3 tumors were localized in the midpetrosal region with spread into the IAC. INTERVENTION: Extended middle cranial fossa approach. MAIN OUTCOME MEASURES: Magnetic resonance imaging and computed tomography were used for follow-up and reevaluation of the operative sites. Facial nerve function and hearing were examined. RESULTS: Complete resection was achieved in 10 (83%) of 12 patients. The retrosigmoid approach was necessary to complete tumor resection in one patient, and in another, partial resection was done because of the en plaque type of tumor growth. There was one unexpected recurrence. All patients retained normal or near-normal facial nerve function postoperatively. Three patients were deaf before surgery, and preoperative hearing level was preserved in 42%. CONCLUSIONS: Attempted hearing preservation surgery is justified in patients with small tumors and preserved hearing, because tumor exposure and safety of resection are comparable with that of hearing-destructive procedures. Lateral extension of the tumor to the fundus does not prevent complete resection with preservation of function, and elective bone resections beyond the visible tumor margins seem not to substantially influence the tumor recurrence rates.

[Inverted papilloma of the nose and paranasal sinuses. Long-term outcome of endoscopic endonasal resection]. / Invertierte Papillome der Nase und ihrer Nebenhöhlen. Langzeitergebnisse nach endoskopischer endonasaler Resektion.

There is still some skepticism about endoscopic endonasal resection of inverted papillomas. We conducted a long-term retrospective study and examined 104 patients (82 male, 22 female) with inverted papilloma who were operated at the ENT-Department of the University of Erlangen between 1974 and 1997. The endoscopic approach was chosen in each case, either alone or in combination with external approaches. In 64.4% (67 cases), tumors of all T-classes were resected by endoscopic approach alone (T1:17.9%, T2:23.9%, T3:41.8%, T4:16.4%). For the rest of the patients an additional transoral and transfacial approach was necessary due to difficult tumor localization (T2:24.3%, T3:29.7%, T4:45.9%). The mean age of the patients was 55 years. The recurrence rate after primary endoscopic endonasal sinus surgery was 22.4% (15/67) and after combined endoscopic and external surgery 16.2% (6/37). Second salvage surgery after endoscopic sinus surgery was performed again endonasally in 46% (7/15) and externally in 53.3% (8/15). The recurrence rate after the endonasal approach was now 57.1% (4/7) and 50% (4/8) after external surgery. Third salvage surgery was performed again endoscopically in four cases and externally in four cases. The recurrence rate in both groups was 50% each, so that up to six operations, either endoscopically or externally, were necessary for complete tumor resection. The longest period for a tumor recurrence was 3.4 years after endoscopic sinus surgery and 9 years after combined endoscopic and external surgery. A tumor recurrence after endoscopic endonasal sinus surgery that could not be managed endoscopically again occurred in 12%. Tumor localization is the limiting factor for endoscopic endonasal sinus surgery of inverted papilloma. However, in 64.4% of cases, endoscopic endonasal sinus surgery alone was performed successfully without any loss of one patient. Long-term follow-up is necessary since the recurrence of tumor can happen after a long time. Endoscopic endonasal sinus surgery of inverted papilloma is safe and should be preferred due to its minimal invasive character.

Arachidonic acid metabolism in nasal tissue and peripheral blood cells in aspirin intolerant asthmatics.

Aspirin intolerance (AI) is characterized by polypous rhinosinusitis, bronchial asthma and adverse reactions to aspirin. The common intolerance to all cyclo-oxygenase inhibitors allows us to focus study of the pathogenesis of AI on the metabolism of arachidonic acid (AA). We studied the metabolism of AA in nine aspirin intolerant asthmatics (AIA) and eight healthy volunteers (controls) by measuring prostaglandin E2 (PGE2) and peptido-leukotrienes (pLT = LTC4/D4/E4) in nasal tissue and peripheral blood cells (PBCs) using a specific immunoassay. In all patients with AI the tests were performed before and after bronchial provocation with lysine-ASA. In the control group the tests were done before and after 500 mg ASA p.o. The release of pLT in nasal polyps of AIA was found to be significantly higher than in normal mucosa of AIAs and controls. In every tissue a significant increase of pLT after aspirin challenge was observed. Nasal polyps of AIA show a significantly lower release of PGE2 than normal mucosa of AIAs and controls. Peripheral blood cells of AIA show a significantly higher release of pLT and a significantly lower release of PGE2 than PBCs of controls. Therefore clinical manifestations of AI may be based on an alteration of AA metabolism in AIA.

[Enlarged middle fossa approach to the cerebello-pontine angle. Technique and indications]. / Voie d'abord sus-pétreuse élargie à l'angle ponto-cérébelleux. La technique et les indications.

Our enlarged middle fossa approach, first published in 1982, aims to expose the internal auditory meatus and cerebello-pontine angle from above, with preservation of the cochlea and labyrinth. The steps of the operation are described, especially certain technical details: the skin incision, resection of the squamous temporal bone, extradural exposure of the petrous temporal bone, subsequent resection of the middle meningeal artery and superior petrosal sinus, extensive bone removal behind and in front of the internal auditory meatus, opening of the dura mater to expose the brain stem, and plastic closure of the defects. Believing in the advantages of this approach, we have modified the technique for various indications, including decompression of the facial and cochleovestibular nerves for cases of vascular compression and Menière's disease; management of temporal bone fractures with CSF leak of facial nerve damage; extensive cholesteatoma of the petrous bone; meningiomas or other tumours of the petrous bone; neuromas of the facial or vestibular nerve. It should be emphasised that the middle fossa approach may be combined with other approaches in the resection of lateral skull base tumours with preservation of the inner and middle ear.

Experimental sensorineural hearing loss following drill-induced ossicular chain injury.

In a guinea pig model, a standardized drill-induced injury to the body of the incus was applied, and the effects on hearing were characterized by electrocochleography. Drilling resulted in a threshold shift within seconds, and after 15 min it averaged 35.7 dB for clicks, 35 dB nHL for 4 kHz bursts, 36.7 dB nHL for 6 kHz bursts and 39 dB nHL for 8 kHz bursts. The deterioration of the threshold shift remained stable throughout the 5-week post-operative observation period. In five animals a disarticulation of the incudostapedial joint was performed prior to drilling, but this did not reduce the threshold shift. Caution is mandatory during drilling around an intact ossicular chain to avoid a permanent sensorineural hearing loss, and disarticulation of the incudostapedial joint prior to drilling has no protective value.

[Function preserving surgery of glomus jugulare tumors. An achievable goal?]. / Funktionserhaltende Chirurgie von Glomus-jugulare-Tumoren. Ein realisierbares Ziel?

In this retrospective study, oncologic and functional results of 24 patients treated for glomus jugulare tumor stages C and D are reported. The surgical approach used was a combined transmastoid-transcervical approach, which was modified according to individual tumor growth. As needed, this was combined with a transtemporal or retrosigmoid approach. Complete tumor removal resulted in a cure rate of 100%. Surgically induced cranial nerve palsies developed in 38% of the patients. In 54% of cases it was possible to retain middle ear function. Seven patients had incomplete tumor removal requiring postoperative irradiation, with tumor progression occurring in 2 patients. Radical tumor removal was modified by efforts to reduce mutilating resections. These results show that individually tailored and combined multidirectional surgical approaches can allow total tumor removal to be performed with lower morbidity.

Cranial nerve and hearing function after combined-approach surgery for glomus jugulare tumors.

In this retrospective study, oncologic and functional results of 46 patients treated for glomus jugulare tumor are reported. The standard surgical approach was the combined transmastoid-transcervical approach, modified according to the individual tumor growth, and eventually combined with a transtemporal or a suboccipital approach. Complete tumor removal resulted in a cure rate of 90%. New-onset cranial nerve palsies developed in less than 22% of patients. In 54% of cases it was possible to retain middle ear function. From a total of 12 patients with incomplete tumor removal and postoperative irradiation, progressive tumor growth was noted in 4 patients, and was controlled by salvage irradiation or surgery. Radical tumor removal by ablative surgery can be modified by efforts to reduce multilating resections. In their place, individually tailored and combined multidirectional surgical approaches may allow total tumor removal with lower morbidity.

Endonasal endoscopic closure of cerebrospinal fluid fistulas at the anterior cranial base.

This study reports our indications and limits for endonasal endoscopic closure of dural defects with a cerebrospinal fluid (CSF) leak at the anterior cranial base, and demonstrates our surgical technique. Fifty-three patients with CSF rhinorrhea were reassessed for the success rate of closure of the CSF leak. Surgery was successful in 98%, and 68% of fistulas were closed endoscopically. A free graft of autogenous mucoperiosteum of the inferior turbinate was the most frequently used tissue for defect closure. The endonasal endoscopic route proved relatively safe for the closure of dural tears, irrespective of the cause, up to about 10 x 10 mm. It is characterized by minimal morbidity because of the preservation of sinus ventilation and bony structures, supraorbital nerves, and olfactory fibers. Defects larger in size, predominantly of traumatic origin, were closed via the transfacial approach. The decision on the surgical approach was additionally based on the extent of the facial soft tissue injuries and the localization of the leak.

Long-term results of surgery for temporal bone paraganglioma.

The only way to resolve the dispute about the effectiveness of surgery versus radiation therapy for glomus tympanicum and jugulare tumors is adequate long-term studies. In a retrospective study with an average follow-up period of 15 years (range 11 to 23 years) we reassessed 11 patients with glomus tympanicum tumors and 11 patients with glomus jugulare tumors. Ten of 11 patients with glomus tympanicum tumor were tumor-free after surgery. A temporary facial palsy and an external meatal wall defect were the only surgical complications. The air-bone gap postoperatively closed to within 10 dB in three patients, to within 20 dB in six patients, and to more than 30 dB in one patient. Nine of 10 patients with glomus jugulare tumor receiving complete resection were tumor-free. Less than half the patients experienced new-onset cranial nerve function loss, and all made satisfactory recovery, eliminating the need for tracheostomy or gastrostomy. In two patients, the hearing could be preserved on the preoperative level, but the majority already presented with deafness. In the long-term, surgery remains a treatment of choice for glomus tympanicum tumors. It is also an extremely effective treatment with low morbidity for glomus jugulare tumors, including those with intracranial extension.

[What should be recommended to a patient with a small radiologically suspected acoustic neuroma?]. / Was soll man einem Patienten mit radiologischem Verdacht auf ein kleines Akustikusneurinom raten?

OBJECTIVE: Criteria for therapeutic decision-making for intrameatal acoustic neurinomas that are suspected radiologically. DESIGN: Retrospective evaluation. PATIENTS: 114 surgically treated patients of the ORL Dept. of the University Erlangen-Nuremberg. OUTCOME MEASURES: Rate of complications. Preservation of facial nerve function and hearing. Preoperative time course of hearing. Reliability of radiological examination. Progression of symptoms and tumor growth. THERAPY: Surgical exposure and complete removal by the enlarged middle cranial fossa approach. RESULTS: In 47% of cases surgery confirmed a neurinoma limited to the internal auditory meatus. In 41%, tumors were larger than expected and had protruded into the cerebellopontine angle, indicating preoperative tumor growth during an average period of 5.4 months before surgery could be completed. The remaining 12% of patients were found to have a facial neurinoma, meningioma or non-tumorous lesion of the internal auditory canal. No permanent neurological deficits or fatalities occurred in any of the patients treated. Facial function was favorable in 88% and moderate pareses or synkineses occurred in 12%. The degree of hearing preservation depended on the preoperative situation. When the preoperative pure-tone average (at 0.5, 1, 2 and 4 kHz) was 30 dB or less, hearing levels of less than 90 dB could be preserved in 70% of cases. Findings also demonstrated that the complication rate and success of function preservation were similar to younger patients in patients older than 60 years (n = 21). Without surgery auditory acuity decreased by 10 dB per year. The volume of intrameatal neurinomas in 7/10 cases followed by MRI doubled during a median following time of 32 months. CONCLUSIONS: Acoustic neurinoma surgery by the enlarged middle cranial fossa approach is a safe procedure with low complication rates. The percentages of preservation of facial function and hearing can be excellent in cases with small tumors and good preoperative hearing. To date no parameter has been found to predict tumor growth or the time course for hearing loss in individual cases. Surgical ablation of radiologically suspected, small acoustic neurinoma by the transtemporal approach is recommended.

Facial nerve involvement in patients with acoustic neurinomas. Examination with magnetic single- and bi-stimulation.

The diagnosis of acoustic neurinomas is usually made by auditory and vestibular testing and magnetic resonance imaging. As clinical involvement of the facial nerve is infrequent, occurring only in large tumours, only little is known about the subclinical involvement of the facial nerve. Transcranial magnetic stimulation of the VIIth cranial nerve in the temporal bone, adjacent to acoustic neurinoma growth, seems to be an adequate instrument for electrophysiological measurements of minimal nerve lesions without clinically obvious facial palsy. In 70% out of 97 patients with surgically and histologically confirmed acoustic neurinomas, obvious elongation of the intratemporal conduction time of the facial nerve was found. This affection was dependent on tumour size. No correlation was found to preoperative or postoperative facial nerve function and hearing function. The latencies of the conduction time showed a tendential increase in patients with a more difficult grade of surgery and of facial nerve preparation due to fibrous adhesions and nerve spreading on the tumour capsule. A completely new stimulation modality, the application of two magnetic stimuli in quick succession, was applied for the first time in acoustic neurinoma patients, and revealed facial nerve involvement by acoustic neurinoma growth. Facial nerve involvement in acoustic neurinoma can be detected by transcranial magnetic stimulation even in patients with small and medium sized tumours but with clinically normal facial function.

[Intraoperative monitoring of the facial nerve in transtemporal surgery of acoustic neurinoma]. / Intraoperatives Monitoring des Fazialisnervs bei der transtemporalen Chirurgie des Akustikusneurinoms.

Acoustic neuroma ablation by the enlarged middle cranial fossa approach results in a low incidence of postoperative facial nerve dysfunction. In 25 consecutive patients with tumors in the cerebellopontine angle with a diameter up to 2.3 cm, intraoperative monitoring of the facial nerve was evaluated. The facial nerve was monitored electrophysiologically with recordings of the spontaneous EMG and electrically evoked potentials (CMAP) from at least three groups of facial muscles. In 4 cases monitoring was helpful for identification and delineation of the facial nerve. The mechanically elicited potentials during tumor preparation and CMAP after electrical stimulation close to the brain stem were compared with the postoperative facial nerve function and the time course of recovery. If the ongoing EMG recordings resulted in potentials below 0.5 mV and the CMAP at the end of tumor preparation was higher than 0.5 mV, facial nerve function was normal in 9 of 10 cases on the first postoperative day. One patient had mild facial palsy. Poor results could be predicted if numerous discharges with amplitudes higher than 0.5 mV and affected CMAP after stimulation near the brain stem were found at the end of surgery. All 3 patients with these findings had facial paralysis at hospital discharge (an average of 9 days after the operation). Recovery from the palsies was found to be prolonged. Intraoperative monitoring of the facial nerve is now used routinely in surgery of the cerebellopontine angle and the internal auditory canal.