[Impact of the COVID-19 pandemic on consultations and diagnosis in ENT practices in Germany]. / Auswirkungen der COVID-19-Pandemie auf Konsultationen & Diagnosen in den HNO-Praxen in Deutschland.

OBJECTIVE: During the first months of the COVID-19 pandemic, there was a significant reduction in the frequency of visits to healthcare institutions. This circumstance influenced the timely diagnosis and subsequential initiation of therapy in almost all specialties. The aim of the present study is to evaluate a hypothetical change in health awareness with regard to outpatient consultations of ENT physicians in Germany. MATERIAL AND METHODS: This study used anonymized data from 146 ENT practices in Germany and included 162,724 patients in Q2 2019, 158,077 in Q3 2019, 128,342 in Q2 2020, and 149,153 in Q3 2020. The first outcome was the difference in the number of patients with at least one visit to these practices between the second and third quarters of 2019 and the second and third quarters of 2020. The second outcome was the number of patients with new diagnoses per practice, defined as diagnoses not previously documented in the database for a given patient. RESULTS: The number of patients per practice was significantly lower in Q2 2020 compared to Q2 2019 (879 versus 1108, p<0.001). There were no significant differences when comparing Q3 2020 to Q3 2019 (1022 versus 1083, p=0.261). Diagnoses of otitis media (-43%), acute upper respiratory tract infections (-42%), chronic upper respiratory tract diseases: (-21%), hearing loss (-20%) decreased significantly in Q2 2020 compared to Q2 2019. There was still a significant decrease in patient numbers for acute upper respiratory tract infections (-26%) and otitis media (-25%) in Q3 2020 compared to Q3 2019. CONCLUSIONS: The presented results are attributable to several facts. Avoidance of doctor´s visits by the patients, reduction of allocation of appointments by practices and consistent obeying of distance and hygiene measures in terms of wearing filtering face masks (e.g. FFP2/KN95).

[Oncology Services for Patients with Head Neck Cancer during Corona-Times - Patients' Perspective]. / Auswirkungen der COVID-19-Pandemie auf die Versorgung von HNO-Tumoren ­ die Patientenperspektive.

OBJECTIVE: COVID-19 pandemic has impact on the oncology service system for tumor patients. What is the view of head and neck cancer patients (HNC) on this situation and which coping strategies were developed? MATERIAL & METHODS: In study 1 PRIO asked 433 tumor patients regarding their impressions/fears during the lockdown between April 15 and May 15, 2020 (online, standardized questionnaire). In 2nd study 292 tumor patients reported their pandemic-induced perceived changes and coping strategies by established questionnaires (WHO-5, MLQ, GrAw-7). An analysis of the HNC-data obtained by standardized questionnaires was performed. RESULTS: Study 1 had 91 HNC, study 2-84 HNC. Study 1 shows high stress levels for the majority of HNC (53,8 %). Personal fears regarding the own disease and therapies (39.6 %) are a central problem. The participants await physical (24.7 %) as well as psychological (21.3 %) consequences due to the pandemic and its current management. During the lockdown the isolation (banned visitors at any hospital) was discussed as critical main point by 58.5 % of HNC patients. Study 2 (after lockdown) underlined the mental stress caused by pandemic. Intensified relations within the families (58/100 points) as well as more intensive experience of nature and silence (58/60 points) are the most perceived changes in corona-times. HNC showed increased own inactivity (MLQ) and depressed well-being (WHO-5) and attention to the moment (GrAw-7). CONCLUSIONS: HNC patients have had high burden and fears due to the COVID-19 pandemic in spring 2020. Their views are important for further strategies to organize and stabilize the oncology service system during further pandemic periods.

Seasonal Variation of Epistaxis in Germany.

AIM: The goal of the present study was to analyze the seasonal variation of epistaxis in ear, nose, and throat (ENT) practices in Germany in 2016. METHODS: The present study sample included patients who received a first epistaxis diagnosis from physicians in 114 ENT practices in Germany between January 2016 and December 2016. The number of epistaxis patients per practice was calculated for each month. A logistic regression model, adjusted for age and sex, was used to calculate the association between epistaxis diagnosis and the month. RESULTS: The authors found a total of 15,523 patients with epistaxis in 114 ENT practices. Of these patients, 55.9% were men and the mean age was 47.8 ±â€Š27.6 years. The highest number of epistaxis patients was found in February (14.89 patients per practice) and the lowest in August (7.22 patients per practice). The age- and sex-adjusted risk of epistaxis was significantly higher in the months of February (OR = 1.32), March (OR = 1.37), April (OR = 1.34), May (OR = 1.35), and December (OR = 1.33) compared with August. CONCLUSIONS: The presentation of patients with epistaxis at German ENT practices shows a marked seasonal variation with a low in the summer, an increase in fall and winter, and a peak in February, March, and April.

Intracranial Nasal Dermoid Sinus Cyst: Transnasal Endoscopic Resection by Open Rhinoplasty Approach, With Intraoperative Video.

Nasal dermoid sinus cysts are rare congenital lesions that may lead to recurrent soft tissue infections and severe intracranial complications. In case of an intracranial extension, the traditional surgical approach includes a frontal craniotomy with significant morbidity. As a less invasive alternative, a transnasal endoscopic approach has been recommended.This report describes the transnasal endoscopic resection of an intracranial nasal dermoid sinus cyst via an open rhinoplasty approach, which achieved a wide surgical exposure with minimal invasivity and ideal aesthetic results. An intraoperative video demonstrates this combination of techniques in this rare skull base/intracranial pathology.

Transoral parathyroid surgery--a new alternative or nonsense?

PURPOSE: In recent years, several endoscopic techniques have been explored in thyroid and parathyroid surgery, but only few gained acceptance among patients and surgeons. Based on extensive human cadaver and animal studies, we developed a technique for transoral partial parathyroidectomy (TOPP), which was performed for the first time in a patient with primary hyperparathyroidism (pHPT). We now report on results and the acceptance of this new technique 2 years after its implementation. METHODS: A pilot study was initiated to recruit a total of 10 patients with benign sporadic pHPT and a preoperatively localized parathyroid adenoma eligible for initial parathyroidectomy. The study protocol was approved by the ethics committee, and an insurance for unforeseen complications and risks was procured. Data of all patients evaluated and operated were prospectively collected, and follow-up examinations were carried out for 19 months on average, which included clinical examinations; ultrasonography; Ear, Nose, and Throat (ENT) investigations; and blood testing. RESULTS: Between January 2010 and May 2012, 75 patients with pHPT and a preoperative localized parathyroid adenoma were eligible for TOPP. After detailed information about the transoral procedure, only five (7 %) female patients consent to undergo TOPP. In three patients, a parathyroid adenoma could be removed via the transoral access, In two patients, the procedure had to be converted to the conventional technique. Median time until resection of a parathyroid adenoma was 122 min (range, 45-175). One patient had a transient recurrent laryngeal nerve palsy, while one patient suffered from a transient palsy of the right hypoglossal nerve and a slight but persisting dysgeusia. Three patients developed a hematoma of the mouth floor and swallowing problems. In four patients, the visual analog scale (VAS) pain score was high (>7) within the first 2 postoperative days. CONCLUSIONS: Although TOPP is feasible, it is poorly accepted by patients and its complication rate is high. Thus, TOPP is nonsense with currently available devices.

Transcervical extirpation of the submandibular gland: the University of Marburg experience.

Surgical excision of the submandibular gland is the treatment of choice for lesions affecting this gland. The data of 87 patients, who underwent a transcervical extirpation of the submandibular gland as a single operation over the past 10 years at a single institution in Germany, were available for analysis. Sialolithiasis (73.5%) was the most common reason leading to excision, followed by benign (18.5%) and malignant tumors (8%). Complications included temporary palsies of the marginal mandibular branch of the facial nerve (5.7%), the lingual nerve (5.7%), and the hypoglossal nerve (1.1%), and wound infections in the form of hematoma (3.4%) and seroma (1.1%).

Epidermal growth factor-induced modulation of cytokeratin expression levels influences the morphological phenotype of head and neck squamous cell carcinoma cells.

The migratory ability of tumor cells requires cytoskeletal rearrangement processes. Epidermal growth factor receptor (EGFR)-signaling tightly correlates with tumor progression in head and neck squamous cell carcinomas (HNSCCs), and has previously been implicated in the regulation of cytokeratin (CK) expression. In this study, HNSCC cell lines were treated with EGF, and CK expression levels were monitored by Western blot analysis. Changes in cellular morphology were documented by fluorescence- and atomic force microscopy. Some of the cell lines demonstrated an EGF-dependent modulation of CK expression levels. Interestingly, regression of some CK subtypes or initial up-regulation followed by downregulation at higher EGF-levels could also be observed in the tested cell lines. Overall, the influence of EGF on CK expression levels appeared variable and cell-type-dependent. Real-time cellular analysis of EGF-treated and -untreated HNSCC cell lines demonstrated a rise over time in cellular impedance. In three of the EGF-treated HNSCC cell lines, this rise was markedly higher than in untreated controls, whereas in one of the cell lines the gain of cellular impedance was paradoxically reduced after EGF treatment, which was found to correlate with changes in cellular morphology rather than with relevant changes in cellular viability or proliferation. After treating HNSCC cells with EGF, CK filaments frequently appeared diffusely distributed throughout the cytoplasm, and in some cases were found in a perinuclear localization, the latter being reminiscent to observations by other groups. In summary, the data points to a possible role of EGFR in modulating HNSCC cell morphology.

Analysis of pneumatization and neurovascular structures of the sphenoid sinus using cone-beam tomography (CBT).

BACKGROUND: The sphenoid sinus is a frequent target of paranasal sinus surgery. Because of the high risk of injuring the surrounding structures (e.g. internal carotid artery, optical nerve) a preoperative imaging is absolutely necessary. PURPOSE: To analyze the possibilities of cone-beam computed tomography (CBCT), which is especially quite a new technique in ENT, in the evaluation of the sphenoid sinus, its surrounding structures, and the corresponding anatomical variations. MATERIAL AND METHODS: This was a retrospective, single-centre study of 580 patients (1160 sides = cases). The Accu-I-Tomo-F17 was used. Pneumatization of sphenoid sinus, course of internal artery, course of optical nerve, and dehiscence of the bony canals were evaluated. RESULTS: In the case of pneumatization a type I (completely missing or minimal sphenoid sinus) was found in two patients (0.3%), type II (posterior wall of sphenoid sinus is in front of the anterior wall of the sella) in 38 patients (6.6%), type III (posterior wall is between anterior and posterior wall of sella) in 332 patients (57,2%), type IVa (posterior wall is behind the posterior wall of sella without air dorsal the sella) in 104 patients (17.9%), and type IVb (similar to type IVa but with air dorsal the sella) in 104 patients (17.9%). In 1025 cases (89.5%) a smooth course of the internal carotid artery was found whereas a free course could be detected in 120 cases (10.5%). Defects of the bony canal of the optical nerve were found in 16.7% and of the internal carotid artery in 2.7% of the cases. The optical nerve showed a free course through the sphenoid in 151 cases (13.7%) and a smooth course in 1007 cases (87.0%). CONCLUSION: CBCT could evaluate all relevant anatomic structures and answer the questions of different anatomical variants. A modified classification of the pneumatization of the sphenoid sinus could be described. Frequencies of anatomical variations are in accordance with the current literature of CT research.

Extracervical approaches to endoscopic thyroid surgery.

There is increasing demand for surgical procedures which avoid visible scars while maintaining optimal functional and ideal cosmetic results, without compromising the safety or effectiveness of the procedure. Endoscopic techniques have been adapted to abdominal and pelvic surgery and increasingly employed over the past three decades. Although hampered by the absence of a natural cavity, endoscopic techniques have been adapted to surgery in the neck for the past 15 years, particularly for the thyroid gland. While earlier attempts at endoscopic thyroid surgery were performed through incisions in or near the midline of the neck, recent techniques have been developed to place the incisions and endoscopic ports extracervically, or at least away from the midline region of the neck, rendering the cosmetic result more acceptable. Most of these approaches are through the axilla, breast, chest wall or a combination of approaches. Visualization of the thyroid and rate of complications with these approaches are equal to those attained with older endoscopic approaches. Careful patient selection is important for endoscopic surgery. Complications unique to the endoscopic approach are mostly related to insufflation of cervical tissues with pressurized CO(2).

Head and neck cancer surgery in the elderly: outcome evaluation with the McPeek score.

OBJECTIVES: There is international consensus that elderly patients with head and neck cancer should be treated curatively, like younger patients. Because of common comorbidities in elderly patients, perioperative complications are likely. The McPeek postoperative outcome score was used to evaluate the success of surgical interventions in patients with head and neck cancer. METHODS: We included 168 patients in the study (56 in the study group, 75 years of age or more; and 112 in the control group, less than 60 years of age). All patients underwent major surgery for head and neck cancer. RESULTS: The median McPeek scores were 8 in the study group and 9 in the control group (p = 0.04). Regression analysis revealed that neither age (p = 0.085) nor the American Society of Anesthesiologists physical status score (p = 0.342) were independent predictors of the McPeek score. Synchronous surgical interventions (p = 0.00051) and duration of surgery (p = 0.0015) had a significant impact on McPeek score performance. CONCLUSIONS: The McPeek score seems to be an appropriate tool for comparing major surgeries for head and neck cancer in different age groups. It is possible to assess the influence of anesthetic and surgical interventions and complications that affect the length of hospitalization. The results confirm that the overall complication rate after surgery in elderly patients does not differ significantly from that in their younger counterparts. Therefore, extended surgical treatment should be offered to both age groups when no serious comorbidities are present. The postoperative outcome seems to depend on the duration and extent of the surgical intervention.

Minimally invasive techniques for head and neck malignancies: current indications, outcomes and future directions.

The trend toward minimally invasive surgery, appropriately applied, has evolved over the past three decades to encompass all fields of surgery, including curative intent cancer surgery of the head and neck. Proper patient and tumor selection are fundamental to optimizing oncological and functional outcomes in such a personalized approach to cancer treatment. Training, experience, and appropriate technological equipment are prerequisites for any type of minimally invasive surgery. The aim of this review was to provide an overview of currently available techniques and the evidence justifying their use. Much evidence is in favor of routine use of transoral laser resection, transoral robot-assisted surgery, transnasal endoscopic resection, sentinel node biopsy, and endoscopic neck surgery for selected malignant tumors, by experienced surgical teams. Technological advances will enhance the scope of this type of surgery in the future and physicians need to be aware of the current applications and trends.

Early side effects after embolization of a carotid body tumor using Onyx.

The case of a 20-year-old woman with a carotid body tumor of Shamblin class III is reported. Ten hours after preoperative direct intralesional embolization with 20 mL Onyx (ethylene-vinyl alcohol copolymer; Micro Therapeutics, Irvine, Calif), the patient showed symptoms of Horner syndrome and deficits of the hypoglossal and glossopharyngeal nerves. Intraoperative examination 12 hours after Onyx embolization revealed a massive swelling of the hypoglossal and glossopharyngeal nerves. The patient's tongue motility and glossopharyngeal function improved after surgery, but Horner syndrome was still present. Owing to the delayed occurrence of these adverse effects, the optimal time of surgical intervention after Onyx embolization should be discussed and perhaps expedited.

Post-tonsillectomy taste disorders.

Gustatory dysfunction is an uncommon complication following tonsillectomy with a potential impact on the quality of life. This retrospective study was undertaken to evaluate the incidence of post-tonsillectomy dysgeusia and its relationship to wound healing and pain. A retrospective chart review of 100 patients who had undergone tonsillectomy between June and December 2008 at a single tertiary care institution was performed. Clinical examination included evaluation of the patient's history and psychophysical testing with cottons soaked with chininsulfate (0.075%; 0.2%), glucose (2%; 10%), citric acid (0.5%; 7.5%) and sodium chloride (0.5%; 2.5%) before, as well as 4 days to 3 months following tonsillectomy at a tertiary care hospital. Anatomical peculiarities, intubation problems, operation time, methods to achieve hemostasis were extracted from the charts. Healing was scored by the physician and pain was scored by the patient. Subjective taste dysfunction was registered in 29 patients 4 days after surgery. In all patients this dysgeusia regressed within weeks. Measured taste function showed lateralized and transient changes. No investigated factor such as pain, operating time, anatomical particularities, wound healing or haemostatic technique were associated with the occurrence of dysgeusia. Transient taste perception changes seem to be relatively frequent after tonsillectomy. Although our results indicate no correlation of even transiently altered taste perception and any of the investigated parameters, this further confirms the clinical impression that gustatory symptoms can occur even after uneventful tonsillectomy. Informed consent should include post-tonsillectomy gustatory dysfunction.

Cutaneous manifestation of myiasis in malignant wounds of the head and neck.

UNLABELLED: Parasitic infestation of the body by dipterous larvae belongs to the most undesirable events in cancer patients with malignant cutaneous wounds. Human myiasis is rare in developed countries of the northern hemisphere but occurs more often in tropical and subtropical regions. Advanced age, poor hygiene, bad housing conditions, vascular disease and diabetes seem to be predisposing factors for myiasis. We report a case of myiasis in an extensive skin metastasis resulting from a primary cancer located in the oropharynx. In the literature there are few reports on myiasis in malignant wounds resulting from malignancies of the head and neck area. Furthermore, guidelines or recommendations for standard treatment options are not available. Therefore a review of the literature with a focus on therapeutical aspects was performed. CONCLUSION: At present the treatment of choice for human myiasis in malignant cutaneous wounds comprises mechanical removal of maggots and, if possible, surgical excision of the lesion. Most important in the treatment of malignant wounds is a thorough rinsing procedure with antiseptic- and/or antibiotic solutions before consistent dressing changes on a daily basis. Here, a complete covering of the wound is indispensable, especially in the summer months.

A devastating outcome after adenoidectomy and tonsillectomy: ideas for improved prevention and management.

OBJECTIVE: To develop strategies that may assist the surgeon to prevent and manage severe bleeding complications after adenoidectomy and tonsillectomy. STUDY DESIGN: Retrospective. SUBJECTS AND METHODS: Expert reports for malpractice lawsuits or professional boards were reviewed. The review was restricted to "deaths" and "permanent generalized neurological deficiencies." RESULTS: Forty-three cases matched our search criteria, including 32 deaths. Adenoidectomy cases (2) were associated with immediate bleeding because of direct vascular injury resulting in one death. Tonsillectomy cases were associated with delayed and repeated episodes of bleeding resulting in 31 deaths, including 19 children. Autopsy verified predominantly aspiration and vascular injuries. An apallic syndrome prevailed in surviving patients. CONCLUSION: Careful inspection of the nasopharynx immediately before adenoidectomy and curettage in a piecemeal fashion under visual control is helpful to prevent direct injury to aberrant arteries. Tonsillectomy cases are associated with delayed and episodic bleeding with spontaneous cessation and young age. Inpatient observation should be strongly considered in cases with repeated bleeding episodes to provide immediate treatment. The follow-up should be focused on disturbed wound healing. Outcome appears to be dependent on adequate airway management. Rigid instruments and tracheotomy in case of intubation failure are highly recommended to facilitate airway protection and ventilation.

From the expert's office: localized neural lesions following tonsillectomy.

Due to various reasons, localized neural lesions following tonsillectomy are presumably an under-reported complication in the literature. This study was undertaken to compile our experiences including a literature review to disseminate useful insights in the etiology and prognosis of this rare entity. A retrospective chart review of expert reports written by at least one of the authors for malpractice claims in relation to tonsillectomy was undertaken. Additionally, a retrospective analysis of 648 patient documents that had undergone tonsillectomy in 2001 at our institution and a comprehensive literature review were performed. The research was restricted to the item "localized neural lesion". Seven cases from the expert's offices, one of our patients who had undergone tonsillectomy at our institution and 122 cases from the literature matched our search criteria. Including our own cases, the glossopharyngeal nerve was affected in 82 patients. Other lesions encompassed injury of the hypoglossal nerve as solitary (15) or combined (5) lesion, recurrent nerve paralysis with (2) or without additional nerve lesions (7), facial nerve paralysis (10) in combination with other nerve lesions (1), and a lingual nerve deficiency as solitary (4) or combined lesion (9). A single report existed for lesion of the phrenic nerve. There were five reported cases with blindness and nine cases with Horner's syndrome. Albeit rare, localized neural lesions may occur as a troublesome complication following tonsillectomy and/or means to achieve hemostasis. Some of these cases may not result from the dissection itself but injection procedures. Surgical dissection should include careful mouth gag insertion and meticulous dissection to minimize the risk of localized neural complications. A long-term follow-up is recommended for patients with dysgeusia related to glossopharyngeal nerve injury and patients with recurrent nerve dysfunction. Other lesions are much less likely to resolve in the long-term. Localized neural lesions should adequately be included in the informed consent for tonsillectomy as well as for surgical treatment of post-tonsillectomy hemorrhage.

Incidence and Risk of Various Disorders of the External Ear in Patients With Hearing Aids Treated in ENT Practices in Germany.

OBJECTIVE: The aim of the study was to investigate the relationship between the presence of a hearing aid (HA) and the occurrence of various disorders of the external ear, using data from ear, nose, and throat (ENT) practices in Germany from a nationwide, representative practice database. METHODS: In the period between 2012 and 2016, the incidences of disorders of the external ear (ICD-10 groups H60 and H61) in patients with HA prescriptions were compared retrospectively with a control group without HA prescriptions (1:1 matching). RESULTS: A total of 20,127 patients with HA prescriptions were compared with 20,127 controls. The highest 12-month incidences (HA vs. controls) were determined for "Impacted cerumen" (H61.2) (16.5% vs. 4.2%), "Unspecified otitis externa" (H60.9) (2.6% vs. 1.2%) and 'Acute noninfective otitis externa' (H60.5) (2.3% vs. 0.7%). The most significant risk increases for HA wearers were found for "Abscess of external ear' (H60.0, OR 10.03), "Other otitis externa' (H60.8, OR 6.00), and "Impacted cerumen' (H61.2, OR 4.55). A smaller risk increase was found for "Cholesteatoma of external ear' (H60.4, OR 2.26), among others. CONCLUSION: In HA wearers, the risk of developing almost all of the diagnoses reviewed is significantly increased, especially for external auditory canal (EAC) furuncle, chronic otitis externa, and impacted cerumen. This study provides the first epidemiological evidence for HA as a risk factor for the rare EAC cholesteatoma.

Demographic data and seasonal variation in peripheral vestibular disorders in ENT practices in Germany.

AIM: The aim of this study was to analyze the demographic data pertaining to and seasonal variation in specific vestibular disorders in ear, nose, and throat (ENT) practices in Germany based on data from a representative nationwide practice database. METHOD: The study sample included patients from 116 ENT practices in Germany who received an initial diagnosis (ICD-10 code) of Meniere's disease (MD, H81.0), benign paroxysmal positioning vertigo (BPPV, H81.1), or vestibular neuronitis (VN, H81.2) between January 2014 and December 2016. Collected parameters included age, sex, and month of diagnosis. Seasonal variation was analyzed for younger vs. older patients (≤50 vs. >50 years of age). Two univariate Poisson regression models were fitted to estimate the association between the month of diagnosis and the number of diagnosed patients per practice. RESULTS: A total of 20,720 patients were available for analysis. The average case numbers for MD, BPPV, and VN were 0.8 patients, 2.7 patients, and 1.5 patients per practice per month, respectively. The mean ages of female vs. male patients were 55 and 56 years (MD), 59 and 60 years (BPPV), and 58 and 57 years (VN), respectively. The proportions of female patients with these diagnoses were 62%, 70%, and 61%, respectively. All diagnoses were evenly distributed throughout the years in all age groups. No seasonal variation was observed. CONCLUSIONS: The demographic data of MD and BPPV patients are comparable to those found by previous large-scale epidemiologic studies. However, no seasonal variation was demonstrated for any vestibular disorder in this large sample.