Flexible versus rigid endoscopy for treatment of foreign body impaction in the esophagus.

BACKGROUND: The use of either flexible endoscopy (FE) or rigid endoscopy (RE) for removal of ingested foreign bodies (FBs) impacted in the esophagus is still discussed controversially. METHODS: We report a consecutive series of 139 patients with FB impaction in the esophagus. During a 6-year period, 69 men and 70 women (median age, 64 [0.7-97] years) requiring removal of an impacted FB underwent either RE (n = 63) in the Otolaryngology Department of our hospital or FE (n = 76) in the Surgical Endoscopy Unit. RESULTS: Foreign body removal was equally effective with FE (success rate 93.4%) and RE (95.2%, p = n.s.). The cases in which foreign body removal failed (5 FE cases [6.6%] and 3 RE cases [4.8%]) were all subsequently successfully managed with "conversion" and use of the other technique. No severe complications occurred when FB removal was attempted with FE (0 of 76 cases; 0.0%), whereas RE was associated with esophageal rupture requiring immediate surgical intervention in 2 of 63 cases (3.2%; p < 0.002). Patient comfort differed significantly between the two procedures (p < 0.0001); RE was always performed under general anesthesia (100.0%), whereas only a minority of patients undergoing FE required general anesthesia (13.0%; p < 0.0001) or mild analgosedation (20.0%). The better patient comfort with FE was also reflected in a significantly lower rate of dysphagia (15%) compared to RE (48%; p < 0.0001). Rigid endoscopy was more frequently used in removal of FBs of the upper esophagus (p < 0.0001), whereas FE was the predominate approach to FBs in the lower esophagus (p < 0.0001). CONCLUSIONS: A tailored approach to treatment of FB impaction is recommended. Because of the lower rate of severe complications, better patient comfort with a lower rate of dysphagia, and lack of requirement for general anesthesia, FE should be the "first line" approach to FBs, although RE has its place as the "second line" therapy.

Facial reconstruction with a unique osteomyocutaneous DCIA perforator flap variant: a case report.

BACKGROUND: Anatomical variance of the deep circumflex iliac artery is of high clinical value in facial reconstruction using a deep circumflex iliac artery perforator (DCIAP) flap. METHODS: We present the case of a 76-year-old woman treated with an osteomyocutaneous DCIAP flap variant for facial reconstruction. We also review here the literature on DCIA perforator flaps and the different anatomical variances, which might bring clinical benefits. RESULTS: The observed anatomy in our patient offered the possibility to raise a free flap variant with high mobility of a large skin paddle and a long vascular pedicle combined with a variable osteomuscular portion. CONCLUSION: The characteristics of the flap thus raised help overcome the disadvantages of the conventional DCIAP flap and offer excellent options for facial reconstruction.

Subacute fatal aluminum encephalopathy after reconstructive otoneurosurgery: a case report.

We report a 52-year-old woman who underwent otoneurosurgery to resect acoustic neurinoma. Bone reconstruction was performed with an aluminium (Al)-containing cement. Six weeks later the patient suffered from loss of consciousness, myoclonic jerks, and persistent grand mal seizures, clinical symptoms that resembled those of lethal dialysis encephalopathy of the 1960s and 1970s. She died 6 months later because of septic complications. Light- and electron-microscopic investigation of the central nervous system (CNS) showed pathognomonic Al-containing intracytoplasmic argyrophilic inclusions in choroid plexus epithelia, neurons, and cortical glia. These changes are characteristics of dialysis-associated encephalopathy (DAE), induced nowadays by long-term ingestion of Al-containing drugs (and with benign clinical courses). Atomic absorption spectrometry showed an increase of mean bulk Al concentration of the cortex and subcortex up to 9.3 microg/g (normal range <2 microg/g); laser microprobe showed the increase of Al in subcellular structures. This unique case again shows the extraordinary neurotoxicity of Al, which was, in our patient, initiated by an amount of about 30 mg Al and apparently caused by direct Al access to the brain parenchyma via a cerebrospinal fluid leakage.

Brain-stem involvement in multiple sclerosis: a comparison between brain-stem auditory evoked potentials and the acoustic stapedius reflex.

Brain-stem auditory evoked potentials (BAEPs) and the acoustic stapedius reflex (ASR) were recorded in 68 patients with definite, probable and possible multiple sclerosis (using the definitions of McAlpine). The high incidence of abnormal results, 68% and 60%, respectively, pointed to the diagnostic value of these two measures in detecting brain-stem dysfunction. Combination of the methods increased the diagnostic yield to 85%. Since in part the same brain-stem generator sites underlie BAEPs and the ASR, it was considered that a study of their correlation might serve to increase the reliability and validity of these techniques. There was 71% agreement overall between results from the two measures. Furthermore, 72% of the joint BAEP and ASR abnormalities corresponded in detection of the brain-stem lesion site. It was concluded that the combined approach may supply powerful, complementary information on brain-stem dysfunction, which may aid in establishing the diagnosis of multiple sclerosis.

Protein distribution in the human perilymph. A comparative study between perilymph (post mortem), CSF and blood serum.

The large differences in the protein content of perilymph and serum as well as the perilymph volume limit of 10-15 microliter cause serious problems when collecting samples of uncontaminated perilymph in order to analyse its protein composition. In 8 out of 24 extremely carefully taken samples of perilymph removed during autopsy, we were able, by keeping to certain selection criteria, to carry out electrophoretic analyses which were suitable for reproduction and comparison. Comparison of human perilymph, CSF and serum, using SDS-Page and Western blotting, gave the expected agreement which had been suggested by tests on guinea pigs. However, a closer examination of individual proteins pointed to some relatively large differences in quantity and quality.

A modern concept of cerebrospinal fluid diagnosis in oto- and rhinorrhea.

Three successive CSF investigations make it possible to identify even the smallest amount of cerebrospinal fluid (CSF) in cases of otorrhea and rhinorrhea: 1. Immunological identification of beta 2-transferrin. 2. Laboratory fluorescein identification. 3. Endoscopic fluorescein detection. As a screening procedure the beta 2-transferrin identification method is always used as the first step towards clarifying a suspect liquorrhea. In addition both fluorescein tests are used for the diagnosis depending on the result of the beta 2-transferrin identification and further measures. As a result of recent practical experience special attention is paid to the test analyses; the various possibilities of taking samples as well as mailing them. A newly developed diagnostic plan of procedure should (by using practical examples) underline the clinical significance. This study describes the most up-to-date level in CSF diagnosis and demonstrates that, when combined with a corresponding X-ray investigation, a much more exact range of indication for the surgical treatment of fractures of the base of the skull and CSF leaks is possible.

[The anterolateral thigh flap: its versatility in oncological soft tissue reconstruction of the head and neck region]. / Der anterolaterale Oberschenkellappen : Seine Vielseitigkeit bei der onkologischen Weichteilrekonstruktion im Kopf-Hals-Bereich.

The anterolateral thigh flap (ATL) has become a standard procedure in reconstructive microsurgery. In this study the results with the ALT for reconstruction in the head and neck area after tumor resection in 33 patients were retrospectively analyzed. Patients included 28 men and 5 women aged 47-70 years who suffered from intraoral and extraoral tumors. Satisfactory soft tissue coverage could be achieved in all patients and no flaps were lost. The ALT is a versatile free flap enabling reliable soft tissue reconstruction of complex defects in the head and neck region. Flap dissection and preparation of the recipient area can usually be performed simultaneously. Additional advantages include the long and strong caliber vascular pedicle, the low donor site morbidity and the different possibilities of tissue composition, making the ALT a workhorse flap in modern reconstructive microsurgery.

[Endoscopic concept and fiberoptic technic in monitoring long-term intubation]. / Endoskopisches Konzept und fiberoptische Technik zum Monitoring bei Langzeitintubation.

An endoscopic procedure has been developed to enable constant monitoring of the mucous membrane of the larynx and trachea. The examination can be divided into four stages. 1. Transnasal inspection. 2. Transtubal inspection. 3. Partial, endoscopically controlled extubation. 4. Endoscopically controlled re-intubation. The advantage of this newly developed technique using a flexible fiberoptic endoscope is that complete extubation is not necessary in patients who are under artificial respiration and subject to long-term intubation. In long-term intubation without artificial respiration care must be taken to provide the best possible means of sedation. Endoscopic monitoring of this kind guarantees the following: 1. Early determination of intubation damage to larynx and trachea. 2. Exact control of the position of the tube, rendering X-ray identification unnecessary. 3. Examination of the bronchial system. 4. A final check on the above-mentioned critical points during complete extubation after long-term intubation. Regular examination by this atraumatic method provides an early diagnosis of any mucosal damage caused by tubes. The recommendation that a secondary tracheotomy should be carried out after 48 h, and at the latest after a week, can no longer be supported, provided the necessary modern anaesthetic equipment and management is available.

Cerebrospinal fluid otorrhea--new trends in diagnosis.

In this paper we describe the different causes of cerebrospinal fluid (CSF) otorrhea and their pathomechanisms, followed by a short description and illustration of the most common methods used until now for identifying CSF. We then present a new and modern method, immunologic identification of CSF using beta 2-transferrin (tau band). This protein variant is found only in CSF, not in any other body fluids, such as tears, nasal secretions, saliva, or blood serum. Analysis of CSF using this method always indicates two bands, the beta 1-transferrin and the beta 2-transferrin band. The latter is typical for CSF. The analysis of all other body fluids shows just one band, the beta 1-transferrin band. It is therefore possible to identify CSF accurately. The required reagents and equipment are listed and methods of taking samples are explained, followed by a detailed description of sample preparation, electrophoresis, immunofixation, and silver staining. Staining with alkaline silver nitrate has a 40-fold higher sensitivity than staining with the commonly used coomassie brilliant blue. With this method, 1 microliter pure CSF (corresponding to approximately 1/50 of a drop) and 100 microliter CSF (two drops) per 1 ml wound secretion can be identified.

[Cerebrospinal otorrhea--cerebrospinal rhinorrhea. The Salzburg concept of cerebrospinal fluid diagnosis]. / Otoliquorrhoe--Rhinoliquorrhoe. Salzburger Konzept zur Liquordiagnostik.

The three following cerebrospinal fluid (CSF) examinations make it possible to identify even the smallest amounts of CSF in case of CSF otorrhoea and rhinorrhoea. 1. Immunological identification of beta 2-transferrin (Oberascher/Arrer) 2. Laboratory fluorescein identification (Oberascher/Arrer) 3. Endoscopic fluorescein detection according to Messerklinger. For screening, and as the method of choice, beta 2-transferrin identification is always used as a first step if there is a suspicion of liquorrhoea. Depending on the result and on further measures, both fluorescein tests are used additionally in diagnosis. Basing on practical experience gained recently, special attention is given to test analysis, the various possibilities of taking samples, and their means of transport or mailing. A newly developed diagnostic step-by-step plan is intended to emphasise the clinical significance by means of practical examples. This concept represents the present state of the art in CSF diagnosis and demonstrates that a much mor precise range of indication is possible in surgery of fractures of the base of the skull and CSF leaks if it is combined with an appropriate x-ray examination.

[Otoneurologic testing in multiple sclerosis]. / Otoneurologische Untersuchungsmöglichkeiten bei der Multiplen Sklerose.

The values of the individual audiological and vestibular examination methods in multiple sclerosis (MS) diagnosis are discussed. Our experience shows that the most accurate indications are provided by acoustic stapedius reflex, brainstem auditory evoked potentials (BAEPs) and vestibular investigation. Other testing processes play only a minor part. Using the three methods mentioned, brainstem injuries can be shown to be present at an early stage. Hence one should always include them in MS-diagnosis as a matter of routine. Of the 85 patients we examined, 72 had definite MS and 13 probable (sub-division according to Mc Alpine criteria): all of them underwent acoustic stapedius reflex test and vestibular investigation (nystagmogram, caloric vestibular test according to Hallpike-Frenzel. The stapedius reflex measurements showed pathological findings of 64/54% and the vestibular test findings of 53/61%.

[Therapy of dirt tattooing]. / Therapie der Schmutztätowierung.

Untreated traumatic tattoo leads to bad cosmetic results. A case of traumatic tattooing is reported, the possibilities of treatment described and the importance of immediate treatment emphasized.

[Psychogenic vocalizations]. / Psychogene Lautäusserungen.

In the first case we are dealing with an eight year old boy who made grunting noises. The second case describes a seventeen year old school girl who suffered from barking coughing attacks. It should be pointed out that the symptoms mentioned had been already observed several months before a diagnosis was made. The actual cause in both cases could be traced back to a disturbed family situation. After a specialized treatment with individual and group discussion as well as the recommendation for behaviour-patterns the complete disappearance of symptoms could be noted in both patients. The pathomechanism was probably a conscious reaction to family conflicts which, however, continued subconsciously after therapy.

[Ofloxacin in the treatment of Pseudomonas aeruginosa infections of the ear]. / Ofloxacin zur Behandlung von Pyocyaneusinfektionen des Ohres.

Twenty-three patients suffering from a Pseudomonas infection of the ear were treated with ofloxacin in a prospective study. The type of infection was as follows: external otitis 4, external otitis with furuncle 3, external otitis and otitis media 5, acute exacerbation of chronic otitis media 7, infection of radical mastoidectomy 3, malignant external otitis 1. All patients had previously been unsuccessfully treated elsewhere. The average period of infection was 13.7 days. The patients received 200 mg of ofloxacin (Tarivid) twice daily for 3 weeks. At the same time the ear was cleaned by suction at 2-4 day intervals and a Normison ear strip applied. Twenty patients were completely cured, 2 patients stopped taking ofloxacin early as a result of improved symptoms but their condition subsequently deteriorated. After a further 3 weeks of consistent treatment both of the cases were also cured. Hence only one patient did not respond to our therapy; that is a success rate of 95%. These results are compared with those of our former therapeutic plan in which all patients with resistant Pseudomonas ear infections were treated as in-patients with selected intravenous antibiotics.

[The eustachian tube in HR computerized tomography. Imaging in the fetus, newborn infant and infant]. / Die Eustachische Röhre in der HR-Computertomographie. Darstellung beim Fetus, Neugeborenen und Säugling.

The lumen of the eustachian tube in foetuses, neonates and infants was demonstrated in cadaver temporal bones immediately after death by air and contrast medium using high-resolution computed tomography with axial and coronal projections. Special consideration was given to the deviation of the tube from the sagittal and horizontal plane and the functional unit consisting of the processes of tensor palatini muscle. At this stage of development the lumen of the cartilaginous portion shows a constant almost circular form, quite unlike the shape in adults. A well developed isthmus between the bony and cartilaginous part is absent. In a 6-month-old foetus the tube is horizontal to the base of the skull, whereas in a 6-month-old infant it forms an angle of approximately 10 degrees. The angle to the sagittal plane changes in the same period from approximately 37 degrees to 40 degrees. In a 6-month-old foetus the fibres of the tensor palatini muscle also run in an almost horizontal line because of the tiny processus pterygoideus and are forced into a steeper direction as a result of its gradual growth. As there is almost no fulcrum function, a tubal opening effect or mechanism of the muscle fibres at this stage of development seems extremely doubtful.

[Goldenhar syndrome and other ear abnormalities in HR-PCT]. / Goldenhar-Syndrom und andere Ohrmissbildungen im HR-PCT.

The use of CT in hospitals in which also ENT departments are located will be useful in cases of osseous congenital disorders of the ear. In combination with the clinical and audiometric investigations CT of the temporal bone will be helpful for the indication of the operations to ameliorate the hearing.

[The Eustachian tube in HR computerized tomography. Imaging in the adult]. / Die Eustachische Röhre in der HR-Computertomographie. Darstellung beim Erwachsenen.

Until now the lumen of the Eustachian tube (ET) has always been shown by using histological sections of temporal bones, which were after decalcification embedded in paraffin blocks and serially sectioned. In order to avoid changes caused by this preparations, we applied contrast medium or air to the lumen of the ET of cadaver temporal bones resected immediately after exitus. It was therefore possible to demonstrate the lumen of the tube in high resolution computed tomography. In this way we could find clear variations of the lumen in the total length of the ET and divide it into five different topographically specific regions. Whereas the pars ossea is formed by certain bone formations and structures in various ways, the picture of the cartilaginous portion remains the same: At the connection of the pars ossea to the isthmus the lumen shows an almost circular form which becomes oval towards the end of the isthmus. This can also be found in the preisthmus portion. In the intermediate section the oval shape is interrupted and replaced by a double curve in the form of a reverse "S". We find once again in the pharyngeal section a well-formed oval lumen, which however is more pronounced than in the preisthmus portion. The intermediate section with its double curve is defined by us beside the isthmus region, as a further, second physiological isthmus in the course of the ET. Apart from that the demonstration of the lumen, that of the function unit of the tensor palatine muscle, processus pterygoideus and hamulus is also of special interest.(ABSTRACT TRUNCATED AT 250 WORDS)

[High-resolution computed tomography in stapes surgery]. / Die hochauflösende Mittelohr-Computertomographie in der Stapes-Chirurgie.

Early and delayed complications in the inner or middle ear may follow stapedectomy or stapedotomy and may require revision surgery. Nowadays high resolution middle ear computed tomography (HR-MCT) using a special interpolation technique can demonstrate the smallest structures of the middle ear space, such as the long process of the incus and stapes. Stapes prostheses can also be seen in this way, but to identify the prothesis exactly it is necessary to determine the position of the piston hook in relation to the incus and of the piston shaft to the foot plate and scala vestibuli. Two points were of particular interest to us: HR-MCT identification of various metal and plastic pistons. Clinical significance of HR-MCT in complications following surgery. As the result of our experimental research on cadaver temporal bones, pistons must still be divided into four groups based on their demonstration by HR-MCT: Group I (e.g. Stainless Steel Cup Piston): whole piston visible. Group II (e.g. McGee Stainless Steel Piston): only piston shaft. Group III (Fisch Teflon-Platinum Piston): only hook visible. Group IV (e.g. Fisch Teflon-Wire Piston): piston hardly visible or not at all. In groups I-III it is possible to discover whether the piston is too long or too short, whether it is dislocated or has slipped. Group IV pistons, hooks from group II and the shaft from group III must be changed to allow detection by x-rays. With plastic pistons it might be possible to add an x-ray agent.2+ improvements in manufacture appear to be necessary, dislocation of various prostheses can now be shown.(ABSTRACT TRUNCATED AT 250 WORDS)

[Preformed, autologous rib cartilage in the reconstruction of defects of the frontal bone]. / Geformter, autologer Rippenknorpel zur Stirndefektrekonstruktion.

The production of exactly fitting, preformed cartilage implants is described. These implants consist of rib cartilage chips that develop after 6 to 9 months' implantation under the thoracic and abdominal skin to a homogeneous and compact cartilage-connective tissue mass. The autologous implants are formed by using plastic shells that are perforated. This technique enables us to repair bone defects of the frontal and skull base region. As well as explaining the surgical procedure the advantages, disadvantages and indications are stressed.

[Immunologic cerebrospinal fluid diagnosis using beta-2-transferrin principles and method]. / Immunologische Liquordiagnostik mittels beta 2-Transferrin-Grundlagen und Methodik.

By using this method beta 2-transferrin, a protein variant can be identified. This variant is produced by neuraminidase activity of the brain and up to now could only be found in cerebrospinal fluid (CSF). In the analysis of CSF, by applying immunofixation with an antiserum and silver staining two bands, the beta 1-transferrin and the beta 2-transferrinband can be demonstrated. When examining serum, nasal secretion, tears, saliva and or other body fluids, only one band, the beta 1-transferrinband can be seen. It is therefore possible to identify CSF accurately. First of all methods of taking samples are explained and required analysis briefly described. Two points were of particular interest to us: The sensitivity of the method and Tracing of possible disturbing effects. Following several, different series of tests we got these results: 1 microliter pure CSF (that corresponds to approx. 1/50 of a drop) and 100 microliter CSF (two drops) per 1 ml nasal secretion can be identified by this method. It is possible that disturbing effects may be caused by blood contamination or a high protein content. For this reason haemoglobin must eliminated by using chromatography. Furthermore it is necessary to reduce a protein content of more than 5 g/l with ammonsulfat precipitation. If care is taken in respect of these two points disturbing effects can be avoided. In clinical application the immunological CSF identification seems to have a very high level of sensitivity and, in comparison with other methods many advantages.