[The risks of autogenous cartilage grafting in laryngotracheal reconstruction in adults]. / Risiko des autogenen Knorpeltransplantats bei laryngotrachealer Rekonstruktion bei Erwachsenen.

BACKGROUND: Laryngotracheal reconstruction with autogenous rib cartilage graft has become a well established surgical method for the repair of subglottic and glottic laryngotracheal stenoses in infants and children. There are far fewer reports on the application of this method in adult patients. In particular, detailed observations of the healing behaviour of autogenous adult rib cartilage grafts are lacking. MATERIAL AND METHOD: The course of disease in five adult female patients (age 25-47 years) who underwent one- or two-stage laryngotracheal reconstruction with rib cartilage grafts are reported. RESULTS: Primary healing was observed in the youngest patient (25 years) only. In the other four patients the cartilage graft had to be partly removed 4-6 weeks postoperatively due to partial necrosis, followed by open wound treatment. As a result of these measures a sufficiently large laryngotracheal lumen could be achieved in all cases. DISCUSSION: Partial ossification of the adult rib cartilage was considered the reason for the observed healing difficulties. Endoscopic follow-up showed that epithelialization of the free endolaryngeal surface of the cartilage graft, i.e. graft healing, takes at least 3 months. Therefore, close endoscopic follow-up during this period appears indispensable.

[Closure of nasoseptal defects in Germany: the current state of the art]. / Nasenseptumdefektverschlüsse in Deutschland: Eine aktuelle Bestandsaufnahme.

OBJECTIVE: 20 years after its first description, the bridge-flap technique according to Schultz-Coulon has proven to be the most successful method by far for the closure of nasoseptal defects. The number of nasoseptal defects being treated in Germany, and the treatment methods being used, are currently an unknown factor. MATERIAL AND METHODS: A questioning survey was sent to all 157 German ENT clinics. They were asked about the number of treatments of nasoseptal defects and the frequency of surgical techniques applied during 2007. RESULTS: 123 questionnaires were evaluated (return ratio=78.3%). In total, 777 nasoseptal defects were treated in Germany during 2007. 31 clinics treated no nasoseptal defects; at 71 clinics, 1-10, at 16 clinics, 11-20, and at 5 clinics, more than 30 nasoseptal defects were treated. 713 nasoseptal defects (91.8%) received surgical treatment, and 64 (8.2%) were treated by inserting a silicone button. With 556 patients (78%), the surgical closures of the nasoseptal defects took place with the help of the bridge-flap technique. CONCLUSIONS: The survey data show a clear tendency towards the surgical care of nasoseptal defects at ENT clinics in Germany. In comparison to the previous school of thought that, in view of doubtful surgical results, symptomatic septal defects should be treated somewhat conservatively, a paradigm shift thereby took place. The fact that in the overwhelming majority of cases (78%), the bridge-flap technique according to Schultz-Coulon is used suggests that the favourable chances of success of this method are mainly responsible for the increasing surgical treatment of nasoseptal defects.

[Life-threatening necrotizing fasciitis colli caused by Serratia marcescens]. / Lebensbedrohliche nekrotisierende Fasciitis colli durch Serratia marcescens.

Necrotizing fasciitis colli is a rare, but life-threatening disease. A 43-year-old female patient was admitted to our department because of increasing dysphagia and slight swelling of the left side of her neck due to severe necrotizing pharyngolaryngitis. Initial treatment with cephalosporin I was ineffective. The patient developed a rapidly spreading necrotizing fasciitis of the neck requiring open surgery for débridement and drainage as well as tracheostomy. Microbiological analysis revealed Serratia marcescens, thus allowing targeted and ultimately successful antibiotic therapy. The case shows that even saprophytes like Serratia marcescens may cause a necrotizing fasciitis. Therefore, the initially calculated antibiotic treatment should include a wide spectrum of aerobic and anaerobic germs.

[Surgical management of inverted papillomas of the nose and paranasal sinuses]. / Zum chirurgischen Behandlungskonzept bei invertierten Papillomen der Nase und Nasennebenhöhlen.

INTRODUCTION: Inverted papillomas require radical resection because of their high recurrence rate and expansive growth and the risk of malignant degeneration. Since the late 1980s surgical resection has been performed predominantly as an endoscopy-/microscopy-aided procedure through an endonasal approach. The extranasal approach is only used in the case of papillomas in unusual locations or ones that have expanded to an exceptional degree. The goal of the present study was a comparative evaluation of the results of this relatively new treatment strategy and of external sinus surgery in our own patients, with particular reference to the recurrence rate. PATIENTS AND METHODS: Since 1989 a total of 80 patients have undergone surgery for inverted papilloma and have been followed up at regular intervals by means of endoscopic examinations. In any patients with a recurrence the revision operation was carried out through an extranasal approach when the papilloma was in the anterior or laterocaudal maxillary sinus or in the frontal sinus; in all other cases an endonasal approach was used for the revision surgery. The mean period of follow-up was 43 months (range 15 months to 16years). RESULTS: In most patients (n=64, 80%) the endonasal surgical approach was used for the primary surgical treatment, while in 16 patients (20%) an extranasal approach was used initially. In 2 patients (2.6%) a squamous cell carcinoma was discovered adjacent to the papilloma. These two therapeutic special cases were not considered evaluable in the analysis of recurrences. Recurrences were seen in 14 patients (17.9%, n=78), in 11 patients after endonasal surgery (17.5%, n=11) and in 3 (20%, n=15) after extranasal resection. The majority of recurrences developed in patients with T3 papillomas. CONCLUSIONS: The recurrence rates observed after endonasal resection are comparable to those after extranasal surgery. Thus, a primary endonasal approach does not mean any prognostic disadvantage. This approach should therefore be given preference over extranasal approaches whenever possible, because there are fewer side-effects and recovery is faster than after extranasal surgery.

[Patients' satisfaction after nasal septal and turbinate surgery. Results of a questionnaire]. / Ergebnisse einer Umfrage zur Patientenzufriedenheit nach Nasenseptumplastik und Muschelbehandlung.

INTRODUCTION: Regarding the satisfaction of patients efficiency and outcome of surgery on the nasal septum and the turbinates regularly is the topic of controversial discussion and occasionally some health authorities doubt there is an indication for these procedures in general. Subjective and objective evaluation of surgical outcome do not necessarily match in all cases. METHODS: A standardized questionnaire was sent to patients having undergone surgery on the nasal septum and the turbinates 33-45 months ago at a university hospital and a non-university hospital. Topics (10 all together) were e. g.: nasal aeration, sense of smell, rhinorrhea, snoring, general condition. Statistic significance of each parameter was verified. RESULTS: 138 questionnaires were reviewed. 82% of the candidates reported better aeration of the nose after surgery. 71% stated to have benefited from the operation. A relevant positive effect on snoring, rhinorrhea, headache and sense of smell could not be proved. The results did no different whether surgery was performed at a university hospital or at a non-university-hospital. Older patients seem to profit more from the procedure than younger ones. DISCUSSION: The survey clearly shows, that surgery on the nasal septum with turbinoplasty has a positive effect on the nasal aeration and the general condition. Therefore its performance is well justified when after careful verification of the pre-conditions the indication for surgery is given.

[Significance of the medical history in decisions on whether tonsillotomy is indicated]. / Wertigkeit der Anamnese bei der Indikationsstellung zur Tonsillotomie.

BACKGROUND: In pre-school children suffering from pure non-inflammatory hyperplasia of the tonsils, tonsillotomy has recently been recommended in preference to tonsillectomy. Absence of inflammatory tonsillitis in the previous medical history is accepted as evidence that tonsillotomy is indicated. In this study, we therefore examine whether and to what degree the medical history correlates with the histological findings. PATIENTS AND METHOD: In a prospective study 59 children admitted to our department for tonsillectomy were each allocated to one of three groups according to how many episodes of acute tonsillitis they had been suffering from per year prior to admission: group 1, 0 episodes of tonsillitis/year; group 2, 1 or 2 episodes/year; group 3, >2 episodes/year. These groups were then compared with the diagnoses yielded by histological examination of the excised tonsils, which were classified into (1) pure hyperplasia; (2) chronic inflammatory tonsillitis; (3) hyperplasia and chronic inflammatory hyperplasia; and (4) chronic inflammation with peritonsillar scarring. RESULTS: In group 1 (n=23) pure hyperplasia was found in only 2 cases, while the tonsils of all other children were affected by chronic inflammatory tissue changes, either alone or in association with hyperplasia. In groups 2 und 3 most tonsillar specimens showed histological characteristics of chronic inflammation, but non-inflammatory hyperplasia alone was also found in 5 cases. CONCLUSION: There is no correlation between the medical history of children undergoing tonsillectomy and the histological diagnosis. In other words, the medical history does not appear to be an appropriate way of reaching a differential diagnosis between non-inflammatory hyperplasia and chronic tonsillitis. This means that tonsillotomy may well leave remnants of chronically inflamed tonsillar tissue in place. Appropriate counselling of the parents seems to be necessary.

[Angioneurotic edema of the head and neck in association with ACE inhibitors]. / Angioneurotische Odeme des Kopf-Hals-Bereiches unter der Therapie mit ACE-Hemmern: Katamnestische Studie 1988 bis 2001.

BACKGROUND: ACE-inhibitors are said to cause angioneurotic edema. In spite of the fact that patients with acute angioedema of the head and neck region are usually admitted to an ENT department, there is only limited information available in the otorhinolaryngological literature on the frequency, risk of recurrent episodes and clinical significance of ACE inhibitor related angioedema. MATERIAL AND METHODS: The medical histories of all patients admitted to our hospital due to acute angioneurotic edema during the period from 1 January 1988 to 31 December 2001 were reviewed. These were supplemented with the results of a standardized questionnaire filed out by the affected patients and of a non-affected control-group. RESULTS: During the observation period. 121 patients were treated for acute angioneurotic edema of the head and neck region. In 34 patients (=28.1%), edema was related to permanent treatment with ACE inhibitors. The overall frequency of angioedema and the percentage of ACE inhibitor related angioedema showed a continuous increase during the study period. There was a latency from the beginning of ACE inhibitor treatment until the first manifestation of angioedema of up to 13 years. In comparison with the group of edema patients without ACE inhibitor treatment, we found a threefold risk of recurrent edema in the ACE group. Women were affected by recurrent episodes more often than men. Until now, any individual assessment of the probable risk of developing an angioneurotic edema during ACE inhibitor treatment appears to be impossible.

[Long-term results after microlaryngoscopic removal of Reinke's edema]. / Langzeitergebnisse nach mikrolaryngoskopischer Abtragung von Reinke-Odemen.

BACKGROUND: In the case of Reinke's edema, the usual aim of microlaryngoscopic vocal fold stripping is an improvement of voice quality. Long-term results concerning functional voice quality in the literature vary widely. Whether and to what degree surgical intervention leads to the desired postoperative results is therefore still an open question. Therefore we conducted a follow-up study to review our own treatment results. MATERIALS AND METHODS: We questioned 88 patients treated for Reinke's edema, either orally or by means of a written questionnaire, 6 months to 7 years (mean: 3.5 years) after the operation (longitudinal incision, removal of the edema by suction, resection of surplus vocal cord mucosa), asking about postoperative voice quality and subjective impression of how successful the operation had been. In all 63 patients answered the questionnaire; 16 agreed to undergo follow-up laryngostroboscopy. RESULTS: 51 patients (81%) reported a postoperative improvement in voice quality, 8 patients (13%) rated their voice quality as unchanged, and 4 patients (6%) complained of deterioration in their voice quality. Among the patients whose voices were subject to professional strain (n=27) a lower proportion experienced successful results (voice quality improved: 71%; unchanged: 21%; worse: 8%) than among patients without vocal strain (n=36; improved: 86%; unchanged: 11%; worse: 3%). Postoperative elimination or restriction of such etiological factors as smoking and vocal strain also improved the long-term results. Follow-up examination in 16 patients revealed a good correlation between the patients' subjective reports and the stroboscopic and auditory findings. CONCLUSION: Patients should be selected very carefully for surgical treatment of Reinke's edema. The elimination of etiological factors is of highly significant in terms of the prognosis. Before surgery patients should be fully informed of how uncertain the prognosis is.

[Comments on septoplasty]. / Anmerkungen zur Septumplastik.

There is a discrepancy between the occasionally heard opinion that septoplasty is an easy operation and its relatively high failure and complication rates. Here we discuss the specific difficulties and possible pitfalls of functional reconstructive septoplasty. The significance of optimal vision using a binocular operating microscope is emphasized. Most of the important measures needed to avoid postoperative complications such as redeviation, pseudo-hump nose or nasoseptal defect are painstaking subperichondrial dissection without injuring the septal cartilage, use of the so-called Cottle-tunnels, sufficient mobilisation and exact straightening of the anterior septal cartilage without remaining tension, stable reconstruction of the posterior septum with cartilaginous and/or bony fragments after selective resection of deviated septal parts, re-fixation of the mobilized anterior cartilage ("swinging-door") to the periosteum of the anterior nasal spine and, perhaps, primary suture of iatrogenic perforations of the mucoperichondrium during the operation. If postoperative complications such as septal hematoma, septal perforation or saddling of the nose are recognized during the first postoperative week, immediate revision surgery is recommended.

[The management of postintubation stenoses in children]. / Management von Postintubationsstenosen bei Kindern.

Extubation difficulties after long-term endotracheal intubation in neonates and infants require immediate re-intubation with a somewhat thinner endotracheal tube, continuation of long-term intubation for another 7-14 days with antibiotic and antiphlogistic therapy including antireflux treatment as well as a subtile endoscopic examination. A tracheostomy is not indicated before several attempts of extubation have failed. An anterior cricoid split should be indicated with great care and in premature neonates only. In manifest cicatrical stenoses, subtile endoscopic diagnostics are an essential prerequisite for the choice of surgical method and time of surgery. In rather mild stenoses (grade II), laryngotracheal reconstruction (LTR) with anterior wall cartilage grafting is presently regarded as method of choice. For subglottic stenoses of higher degrees (grade III and IV), partial cricotracheal resection (PCTR) is felt to be the most successful procedure. For all scarred stenoses involving the glottic level, LTR with posterior and anterior wall cartilage grafting appears to be the only suitable treatment. LTR with anterior wall grafting only as well as the PCTR can be performed as a single stage procedure with postoperative long-term intubation on an intensive care unit for one or more days. LTR with posterior and anterior wall grafting requires long-term stenting for several weeks or months depending upon the individual condition. For long-term stenting, our so-called double-tube-technique using a modified Montgomery T silicon tube together with a perforated tracheal cannula has proved to be the safest and least irksome technique.

[Stenosing gastric laryngitis in infancy]. / Stenosierende Laryngitis gastrica im Säuglingsalter.

A 2 month old female infant presented an aphonic voice and increasing inspiratory stridor due to a stenosing granulating laryngitis. A pathologically elevated gastroesophageal reflux was measured by means of 24-h pH-metry. After antireflux therapy (Cisaprid, sodium alginate and upright body positioning), the laryngitis was completely healed. This case confirms that an elevated gastroesophageal reflux in infants can cause chronic inflammatory diseases of the upper respiratory tract, especially of the larynx.

[On the accumulation of tonsillectomies in young females]. / Zur Tonsillektomiehäufung bei jungen Frauen.

BACKGROUND: The clinical observation of an accumulation of tonsillectomies in young women raises two questions: (1) Can this observation be proved statistically? and, if yes, (2) are there any hints as to a possible psychological reason of this phenomenon? MATERIAL AND METHODS: A total of 24 young females (15-20 years old) admitted to the ENT-department for tonsillectomy were given a preoperative personality screening using the Freiburger personality inventory (FPI-R). RESULTS: A significant, sex specific accumulation of tonsillectomies was found in females aged 10-20 years. The personality screening revealed a significant increase of the subscales "social orientation" and "aggressivity" in the entire group. Eight out of the 24 females showed an abnormal personality profile with statistically unexpected correlations between the subscales "somatic complaints", "excitability" and "aggressivity". CONCLUSION: In spite of the low sample size, these results suggest that in some young females in the postadolescent age group, an abnormal personality structure influences the indication of tonsillectomy.

[Clinical manifestations of diffuse idiopathic skeletal hyperostosis (DISH)]. / Manifestationsformen der diffusen idiopathischen Skeletthyperostose (M. Forestier) in der HNO-Heilkunde.

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH, Forestier disease) is in most cases a harmless, asymptomatic disease characterized by a massive, noninflammatory ossification with intensive formation of osteophytes affecting ligaments, tendons, and fasciae, especially of the spinal column. If the disease becomes symptomatic at all, the leading complaints will usually be dysphagia in the sense of a lump in the throat and difficulty in swallowing. However, in rare cases the osteophytes may influence the laryngeal function ranging from hoarseness and immobility of the vocal cord to life-threatening inspiratory stridor. Such laryngeal manifestations are almost unknown. PATIENTS AND METHOD: We report on three patients, two female and one male, suffering not only from chronic dysphagia but also from increasing inspiratory stridor and difficult breathing. RESULTS: Especially one case illustrates how difficult it can be to establish the etiological relationship between a cancer-like ulcer in the postcricoid region and a bilateral inactivity of the vocal cord on the one hand and DISH on the other hand. Only the resistance of the ulceration to any therapy as well as rare case reports in the literature confirmed our suspicion that the ulcer and disturbance of laryngeal function were caused by chronic pressure exerted by the huge vertebral osteophytes. In all three patients surgical resection of the osteophytes resulted in complete relief of complaints. CONCLUSION: Uni- or bilateral immobility of the arytenoids, possibly associated with chronic inflammatory hyperplasia of the tissue of the arytenoids and the postcricoid region, may be a symptom of an unusual manifestation of DISH.

[Morphological and functional results of Palisade Cartilage Tympanoplasty]. / Morphologische und funktionelle Ergebnisse der Knorpelpalisadentympanoplastik.

BACKGROUND AND OBJECTIVE: The application of cartilage in tympanoplasty has been generally accepted, because cartilage as a bradytrophic tissue allows stable and functionally reliable reconstruction of the eardrum even in difficult pathological conditions (such as subtotal defects, tympanosclerosis etc.). A special surgical technique using small cartilaginous chips for the reconstruction of the eardrum has been developed by J. Heermann, who introduced it as Palisade Cartilage Tympanoplasty (PCT). Although being increasingly applied in otosurgery, this technique has to date neither been evaluated regarding morphological and hearing results nor regarding its combination with titanium ossicular reconstruction prostheses. PATIENTS AND METHODS: Therefore we reviewed 84 of 94 ears (92 patients, 58 female, 34 male) 12 to 36 months after PCT. RESULTS: A recurrent defect was seen in 2 ears (1 adhesive otitis, 1 subtotal defect). There were no extrusions of prostheses. Preoperatively an ear-bone-gap of 0-10 dB was seen in 2 ears, 11-30 dB in 48 and 31-59 dB in 34 ears. Postoperatively the corresponding numbers were 25, 50 and 9 ears. CONCLUSIONS: The low rate of recurrent tympanic membrane defects (2.4%) shows that palisade cartilage tympanoplasty is particularly appropriate for the management of difficult indications in middle ear surgery. Further, it could be demonstrated that the PCT can be combined safely with titanium ossicular reconstruction prostheses. Regarding postoperative hearing results the negative preselection of pathological conditions has to be considered.

[Posterior crus stapedectomy: an obsolete method in otosclerosis surgery?]. / Die Verlagerung des hinteren Steigbügelschenkels. Eine vergessene Methode der Otosklerosechirurgie?

BACKGROUND: Stapedectomy and stapedotomy with interposition of prostheses are the methods of choice for surgical treatment of otosclerosis. For the present study we resumed and reevaluated the posterior crus stapedectomy, a method based on the principal of renouncing a prosthesis by cutting the posterior crus of the stapes close to the footplate and the anterior crus close to the stapes head. METHODS: The posterior crus is temporarily transposed with the incudostapedial joint remaining intact. After performance of platinectomy and sealing of the oval window with fascia it is repositioned onto the center of the window. RESULTS: 19 of 20 ears operated on applying this technique showed good results (closure of air bone gap) after a mean follow up of 24.6 months. One patient showed persistence of air bone gap of 32.5 dB. Revision surgery revealed that the posterior crus had migrated to the posterior rim of the oval window. No inner ear affection, perilymph fistula or sensorineural hearing loss were observed. CONCLUSIONS: The major advantage of this technique is the avoidance of incus necrosis and foreign body reactions related to the material of the prosthesis. Disadvantages are technical plus the longer duration of the procedure.

[Ocular myositis. A rare differential diagnosis of sinus-induced orbital complications]. / Die okuläre Myositis. Eine seltene Differenzialdiagnose der sinugenen orbitalen Komplikation.

Orbital myositis is an uncommon subgroup of the nonspecific orbital inflammatory syndromes (previously termed orbital pseudotumor) and presents with eyelid swelling and redness, conjunctival chemosis, pain, proptosis, and diplopia. The disease is to date of unknown origin; autoimmune processes are suspected for the etiology. In the case of an otherwise healthy young male patient (age 28 years), the coexistence of chronic sinusitis primarily led to the diagnosis of sinugen orbital cellulitis. Despite antibiotic drug administration and surgical drainage of the paranasal sinuses the symptoms persisted. A second computed tomography revealed fusiform, inflammatory enlargement of the m. rectus lateralis. This muscle showed a restrictive paresis so that initially the m. rectus medialis was suspected to be paretic. The patient responded dramatically to administration of prednisolone within 2 days. The differential diagnosis between a sinugen orbital complication and orbital myositis is significant because corticosteroids are contraindicated for orbital cellulitis whereas they remain the therapy of choice for orbital myositis.