Indications, complications, and surgical techniques for pediatric tracheostomies--an update.

BACKGROUND: With the decrease of life-threatening obstructive upper airway infections and the ongoing improvement of intensive care medicine, the role of tracheostomy in children has been changing considerably, until now. The aim of this study was to establish data regarding indications, complications, and techniques of pediatric tracheostomy, which would reflect the current state of science. METHODS: The authors analyzed the international literature as well as their own experience with 25 children less than 6 years of age who were operated on between 1980 and 1996. RESULTS: Literature proved to be very heterogeneous in terms of terminology, patient groups, operation techniques, indications, and complications. Within the past decades, long-term intubation and congenital anomalies of the upper respiratory tract have become increasingly prevalent, whereas inflammatory diseases were less and less an indication for tracheostomy. Endotracheal intubation as an alternative has resulted in less frequent tracheostomies in general. Today, children can be ventilated for months without considerable complications. However, individual, clinical, and fiberoptical controls are necessary. Tracheostomy-related complications have not changed significantly. Fatalities are mostly caused by the underlying disease. The most frequent causes of tracheostomy-related death are cannula obstruction and accidental decannulation. The most frequent early complications are pneumomediastinum, pneumothorax, wound complications, and bleedings. Subsequent complications most often are granulations and tracheal stenosis. CONCLUSIONS: The authors' research agreed widely with that in the literature. However, no tracheostomy-related death occurred. Possibly, this was because of their operative technique. In the opinion of the authors, establishing a cartilage window facilitates cannula exchange and reduces the risk of a fatal accidental decannulation.

Late lethal secondary hemorrhage after laser supraglottic laryngectomy.

Since 1971, a number of articles have been published regarding the complications encountered with laser surgery of the larynx. Most investigations focus on complications such as accidental burns caused by the reflection of the laser beam, endotracheal explosion, special anesthesiologic problems, edema of the mucosa leading to airway obstruction, and abnormal scar formation with functional problems. Secondary hemorrhage has played a subordinate role, and in the few articles that have focused on it, cases requiring postoperative treatment have been reported only sporadically. All of these cases occurred within the first postoperative week, and no case resulting in the death of a patient was reported. We describe a patient in whom a lethal secondary hemorrhage occurred 10 days after a laser supraglottic laryngectomy. Because of the increase of laser applications in the treatment of laryngeal carcinoma, similar complications may be encountered. We comment on possible pathophysiological mechanisms and consequences.

Intraoperative radiotherapy for pre-irradiated head and neck cancer.

BACKGROUND AND PURPOSE: Radiotherapy of recurrent head and neck tumours is limited in dose due to pre-treatment up to normal tissue tolerance doses. Surgery alone is limited by the problems related to pre-surgery, post-radiation fibrosis, and infiltration of tumours into nerves and vessels too closely to be completely removed. Our aim was to evaluate the possible role of intraoperative radiotherapy (IORT) in such tumours treated with palliative intent. METHODS: In the last 10 years, we performed 113 intraoperative irradiations in a total of 84 pre-irradiated patients with head and neck cancer. The patient data were evaluated with regard to palliative effect, complications of treatment, recurrence and survival after IORT. RESULTS: Palliation of symptoms, as assessed by clinical evaluation, was achieved in 88% of symptomatic patients, often just by removal of large exophytic or exulcerating tumours, with IORT preventing their immediate recurrence after surgery. The complication rate did not exceed that expected after surgery alone. The median survival after IORT was 6.8 months, with a median time to local tumour recurrence or progression of 3.7 months. CONCLUSION: Intraoperative irradiation can be used as a palliative treatment option in pre-treated head and neck tumours with satisfactory results. With large and infiltrating tumours, however, recurrences or tumour progression occur close to the IORT portals, thus rendering this method unsuitable for achieving long-term control in such extended tumours.

Development of computer-aided surgery for otorhinolaryngology.

Computer-aided surgery (CAS) describes a method that allows intraoperative navigation in the surgical field based on digital image data such as computed tomography, magnetic resonance imaging, and others. A computer processes the image data in real time and is intraoperatively connected to a measuring system for coordinate determination. CAS has been used in ENT surgery since 1986, and we developed several generations of CAS systems. A passive robot arm was employed in the first approach. Then electromechanical and infrared optical coordinate-measuring devices followed. CAS was applied to several fields of otorhinolaryngologic surgery, including the paranasal sinuses, the orbit, the rhino- and otobasis, and others. CAS was found to be particularly useful for acoustic neuroma removal, paranasal sinus surgery in cases of massive disease or revision surgery, decompression of the orbit or optic nerve, extraction of deep-seated foreign bodies, stereotaxy-like biopsies, and educational purposes. CAS in its current state of development is a useful tool that can be applied routinely; however, further technical developments are necessary.

Intra-operative radiotherapy--5 years of experience in the palliative treatment of recurrent and advanced head and neck cancers.

Recurrent and advanced cancer in the head and neck region is usually associated with limited therapeutic concepts and a dismal prognosis. Efforts mainly focus on palliative treatment in order to improve the patient's quality of life. From May 1989 to December 1994, a total of 120 intra-operative radiotherapy (IORT) procedures with high-energy electron beams (mean energy: 7 MeV: mean dose: 20 Gy) were performed in 95 patients. Therapy was usually performed under endotracheal anaesthesia (84%). There were 91 cases (75.8%) of recurrence in the lymph nodes of the neck and 14 cases (11.7%) of local recurrence. 15 patients (12.5%) received IORT as part of the initial treatment. Considering the palliative nature of IORT in these patients, only an R2 resection (gross residual tumour) was achieved in 71.7%. Local tumour control was nonetheless possible in 17% (R2 resection) to 64% (complete R0 resection), with a mean 11-month follow-up period for survivors (mean for deceased patients: 8 months). Regarding palliative criteria, IORT proved to be feasible since patients profited from short hospitalisation (median: 10 days), a low complication rate (27 instances; e.g. tracheostomy: 11; necrosis: 8, or fistula: 3) and, in part, a substantial reduction of pain (73.8%). Most of them regained physical and psychic integrity for weeks to months and were able to take part in social life during the final stage of their disease.

The paranasal sinuses in CT-imaging: development from birth to age 25.

Available data about the size of the different sinuses to date are derived from anatomical or radiological studies. In order to verify or possibly correct the findings of other authors we evaluated the cranial computed tomography (CT)-images of more than 5600 patients. We measured the sex-linked and age-dependent width and length of the four sinuses for both sides in axial sections. For the first time we have a clear picture of the development of the paranasal sinuses for both sexes from birth until the age of 25 years. Our results confirm general ideas concerning the size of the sinuses. Moreover they provide new details, especially about the first occurrence and the course of development in different stages since we found each sinus already present in 1.5% (frontal sinus) to 94% (ethmoid cells) of the newborn of both sexes. Finally, we can state that the periods of expansion are equal in both sexes (ethmoid cells) or last up to 2 or 3 years longer (frontal sinus) in male patients. In agreement the sinuses of both sexes differ between 5.4% (sphenoid sinus) and 17.1% (frontal sinus) in definitive size with statistically significant differences in later ages. The data about sphenoid sinuses deserve special attention since they show a large variability in size (up to 214% in one direction) as well as in shape.

The computer-assisted localizer, a navigational help in microneurosurgery.

The computer-assisted-localizer (CAL) achieves a direct linkage between preoperative radiological images and individual intraoperative anatomical findings. Experiences with our system demonstrate that CAL improves the intraoperative orientation and facilitates the neurosurgical procedure. The system described here consists of a mechanical articulated robot arm with six degrees of freedom and a three-dimensional image processor. After calibration, the displayed image dynamically pointed out the exact intraoperative localization in three perpendicular sectional views. Meanwhile, CAL was successfully used in 73 selected microneurosurgical procedures.

[A new suture device for continuous sutures in the intestinal tract]. / Eine neue Nähmaschine für fortlaufende Nähte am Intestinaltrakt.

A new surgical sewing device for continuous sutures of gastrointestinal anastomoses with needle and suture material was used for the first time to construct a latero-lateral enterostomy (functional end-to-end anastomosis) in the small intestine of pigs. In ten animals the course was mainly uneventful during the observation period of 10 days. One animal developed a postoperative anastomotic leakage. In five cases adhesions between the anastomotic region and the small intestine were found on postmortem examination, but there was no evidence of any slight leakage. On the whole, the sewing device operated faultlessly. At present, clinical use seems possible for long sutures, which are time-consuming when sewn manually, but it is still premature. One major disadvantage of the device is its size, which restricts its application to extra-abdominal tasks. Nonetheless, the principle of a mechanical device for running sutures should be investigated further.

Computed tomography and magnetic resonance imaging in the preoperative work-up for cochlear implantation.

The role of CT and MRI in the evaluation of patients for possible insertion of a multichannel intracochlear hearing device was appraised. The study included 52 patients who underwent both CT and MRI examinations, 40 of whom were later operated on. Coronal and axial T2-weighted spin-echo sequences were performed in 25 volunteers with normal hearing and in 47 adult patients. In 5 patients, instead of a T2-weighted spin-echo sequence, a T2*-weighted gradient echo 3D sequence with axial presaturation was used. In 39 patients with normal appearances on CT and MRI, the implant device was successfully inserted. One patient who underwent surgery had a reduced cochlear signal on MRI but a normal CT scan; however, at surgery, the implant device could only be inserted into the first turn of the cochlea, due to fibrous obliteration. In 3 of 12 patients who were not operated upon, the results of diagnostic imaging indicated that the insertion of an intracochlear hearing device was not useful. Our experience indicates that, with reduced cochlear fluid signal intensities on MRI, fibrous obliteration of the cochlear turns is likely to be present. MRI proved to be a useful adjunct to CT, but the latter was necessary for the evaluation of bony abnormalities. Gradient echo sequences can successfully replace time-consuming T2-weighted spin-echo sequences.

[Peritonsillar abscess in the ultrasonic image]. / Der Peritonsillarabszess im Ultraschallbild.

A prospective study was carried out to evaluate the sensitivity of ultrasonography in diagnosis of peritonsillar abscess (Quinsy). In 1986 through 1989 all cases of doubtful peritonsillitis were subjected to B-mode ultrasonography of tonsils before tonsillectomy was carried out. 36 patients were included in this clinical study. In cases of clinically uncertain peritonsillar abscesses the sensitivity of the method was 82%. However, only four false positive cases ("abscess in the scan but no pus during surgery") occurred.

[A pragmatic assessment of sense of smell]. / Eine pragmatische Geruchsprüfung.

A new clinical odour test was developed and validated in a clinical trial including 50 healthy volunteers as well as 35 patients suffering from smell disorders. The aromas were incorporated in an inert gas under disclosure from oxygen, avoiding impairment caused by oxidative transformation. Conventional smell test by Elsberg bottles was used as standard. The spray test proved to be equally effective in discriminating subjects suffering from smell disorders as the standard procedure. Moreover the spray test is feasible and long term constance of the substances is guaranteed.

[Cochlear implants in patients with radical cavity]. / Cochlear Implants bei Patienten mit Radikalhöhle.

Treatment of patients with severe bilateral hearing loss by cochlear implants usually requires normal temporal bone anatomy. The authors report one case in which the electrophysiological criteria for cochlear implant were fulfilled. However, the patient showed unfavourable anatomy because of a radical mastoid cavity on the suitable side and a congenital anomaly on the opposite side. As a first step the radical cavity was opened from a retroauricular incision and completely de-epithelialized. Thereafter, a retroauricular full-thickness skin flap was formed and rotated into the cavity; the retroauricular incision was not closed. Six months later a cochlear implant (Clark-Nucleus system) was positioned after undermining the flap described above. This surgical technique allows us to provide patients with radical cavities with implants under the usual sterile conditions and avoids contact of the implant with the body surface.

[CAS (computer assisted surgery). A new procedure in head and neck surgery]. / CAS (computer assisted surgery). Ein neuartiges Verfahren in der Kopf- und Halschirurgie.

Computer assisted surgery (CAS) is a new imaging technique designed to assist the head and neck surgeon during surgery. This method is based upon a three-dimensional volume model of the patient's skull generated by computer tomographic imaging procedures such as CT and MR. Body points can be marked in the 3-D model by intra-operative correlation of model and patient using a volume digitizer. Real-time positioning of surgical instruments without visual control can be achieved. The use of the system in surgery of the skull base, orbit and the paranasal sinuses is demonstrated.

A new imaging method for intraoperative therapy control in skull-base surgery.

CAS-computer assisted surgery-is a new imaging method supporting skull base surgeons. Support is granted not only for preoperative planning of therapy but also for pathfinding during surgery itself and in the postoperative phase as therapy control. The CAS-system consists of high technology items such as -a digital image generation system (CT, MR) -a real-time image processing system -a 3 D position recognition system. Robotics are not incorporated in this system but a hand-guided manipulator houses the surgeon's instrument. Accuracy of the method has been experimentally determined to be within 1 mm. Follow up systems are under development to permit microsurgery support as well.

[Therapy of herpes simplex and varicella zoster infections in the ENT area]. / Zur Therapie von Herpes-simplex- und Varicella-zoster-Infektionen im HNO-Bereich.

The article reports on 41 patients having infections induced by Herpes simplex and Herpes zoster virus. Systemic intravenous administration of acyclovir results in a very rapid reduction of pain and mucosal changes in herpetic stomatitis. In cutaneous lesions of the trigeminal nerve branches induced by Herpes zoster virus there is also a very rapid reduction of pain and efflurescence after 3 days. In 16 patients suffering from Ramsay Hunt syndrome, also known as Herpes zoster oticus, lesions of the facial nerve function were present. 8 Patients demonstrated cochleovestibular signs and symptoms, 2 had flat inner ear hearing loss of 40 dB, 1 reduced unilateral caloric response. Treatment was effected by intravenous administration of acyclovir and simultaneous classical symptomatic therapy consisting of intravenously administered dextrane, cortisone and antiinflammatory drugs. Symptomatic therapy is necessary because acyclovir stops the replication of viruses but does not influence the disturbed nerve function. In 2 cases with a damage of more than 90% of the facial nerve fibres, endaural decompression of the geniculate ganglion was performed. Cochleovestibular deficits improved to normal during one week and all facial lesions within 8 months. Drug-related side effects were seen in one patient who had an exanthema.

Diagnosis and grading of malignancy in squamous epithelial lesions of the larynx with DNA cytophotometry.

For diagnostic purposes 14 histologically benign, 15 dysplastic, and 16 malignant squamous epithelial lesions were subjected to DNA cytophotometry. Results were computed according to an algorithm for DNA diagnosis and grading of malignancy. In cases of unequivocally malignant or benign lesions all DNA diagnoses agreed with the histologic diagnoses. In one case the allegedly faulty DNA diagnosis of cancer was proven to be correct on clinical follow-up. Within the group of histologically mild to moderate dysplasias the algorithm identified four cases as malignant that were proved to be malignant either in the follow-up or at another site of the same lesion. With the aid of the DNA malignancy grade two groups of patients with squamous epithelial carcinomas of the larynx could be discerned with a highly significant difference according to their survival times.

[Vocal cord paralysis with stridor caused by interarytenoid fibrosis--a complication of intensive care]. / Stimmbandstillstand mit Stridor infolge Interarytänoidfibrose--eine Komplikation in der Intensivpflege.

Translaryngeal long-term intubation in intensive-care patients was followed in three cases by immobilisation of the vocal cords and severe stridor, caused by a fibrotic scar between the processus vocales and the posterior commissure. Different surgical approaches are described. Endoscopic incision of the scars is recommended. Most important is a bolting technique for several consecutive days.

[Directional hearing and understanding of speech in noise uith "normal hearing" people (author's transl)]. / Richtungshören und Sprachverstehen unter Störschall-einfluss bei "normalhörenden".

Directional hearing and the ability to understand speech against a noisy background depend among other factors on the binaural signal processing mechanisms in human hearing. In present the practical audiometry can not prove completely the operation of binaural signal processing. This fact will be shown here with three patients who complain of bad understanding speech, but in audiometric tests seem to hear normally. In free field tests of directional hearing and understanding speech against a noisy background they differ clearly from a reference group of normal hearing people.