[Segmental tracheal resection for the treatment of tracheal stenoses]. / Tracheasegmentresektion zur Behandlung trachealer Stenosen.

BACKGROUND: Segmental tracheal resection is considered to be the standard treatment of tracheal stenoses. MATERIALS/METHODS: During the time period 1985-2002, segmental tracheal resection with a primary end-to-end anastomosis was performed in 117 patients with a cervical or upper thoracal stenosis of the trachea. The age distribution of the patients was between 7 and 77 years. Of the patients with a benign tracheal stenosis, sufficient data for a retrospective analysis were available in 101 patients. The length of the resected tracheal segments varied between 2 and 6 cm which required mobilisation of the trachea and the larynx and, if necessary, incision of the pulmonary ligament. RESULTS: In 5 patients a permanent damage of the recurrent laryngeal nerve was seen, of which 4 had undergone revision surgery and 10 months after surgery 93% presented with a large and stable tracheal lumen without any relevant restenosis. Due to a restenosis of 70-80% causing dyspnea at rest, 3% of the 101 patients had to undergo revision surgery. In 4% a mild and asymptomatic restenosis of 30-40% was seen which did not require any further treatment. CONCLUSION: These results demonstrate that segmental tracheal resection can safely and effectively remove stenotic tracheal segments of up to 6 cm and is therefore the treatment of choice.

Origins of and implementation concepts for upper airway stimulation therapy for obstructive sleep apnea.

Upper airway stimulation, specifically hypoglossal (CN XII) nerve stimulation, is a new, alternative therapy for patients with obstructive sleep apnea hypopnea syndrome who cannot tolerate positive airway pressure, the first-line therapy for symptomatic patients. Stimulation therapy addresses the cause of inadequate upper airway muscle activation for nasopharyngeal and oropharyngeal airway collapse during sleep. The purpose of this report is to outline the development of this first-in-class therapy and its clinical implementation. Another practical theme is assessment of the features for considering a surgically implanted device and the insight as to how both clinical and endoscopic criteria increase the likelihood of safe and durable outcomes for an implant and how to more generally plan for management of CPAP-intolerant patients. A third theme is the team building required among sleep medicine and surgical specialties in the provision of individualized neurostimulation therapy.

Squamous cell carcinoma of the oropharynx: Ki-67 and p53 can identify patients at high risk for local recurrence after surgery and postoperative radiotherapy.

PURPOSE: To assess the prognostic value of biologic (p53, Ki-67) and clinical factors in squamous cell carcinoma of the oropharynx after radical surgery and postoperative radiotherapy (RT). METHODS AND MATERIALS: Between 1985 and 1995, a total of 102 patients with 104 tumor sites were entered onto the study. Fifty-five primary tumors (53%) involved the tonsils, 26 (25%) the soft palate, and 23 (22%) the base of the tongue. Median age was 53 years (range 36-80 years). The clinical T- and N-categories (UICC 1997) were: T1 (30), T2 (47), T3 (22), T4 (5), N0 (33), N1 (28), N2 (42), and N3 (1). Histologically-clear margins were achieved in all patients by initial surgery. Postoperative RT to the primary and regional lymphatics was given, to a total of 60 Gy in 6 weeks, and single daily fractions of 2 Gy. The expression of the nuclear p53- and Ki-67-labeling index (LI) was investigated by immunostaining using the monoclonal antibodies DO-7 and MIB 1. The nuclear p53-intensity (p53-I) was graded into 4 categories (0/+/++/) by densitometry. Median follow-up was 43 months (range 14-132 months). RESULTS: Cancer-specific survival, disease-free survival, and locoregional tumor control rates were 74%, 69%, and 75%, respectively, at 5 years. Significant prognostic factors for disease-free survival were: T-category (T1/2: 77% vs. T3/4: 53%, p = 0.02), tumor site (tonsils: 79% vs. soft palate: 70% vs. base of tongue: 45%, p = 0.05), duration of RT (< or = 46 days: 80% vs. > 46 days: 60%, p = 0.04), Ki-67 LI (< or = 20%: 84% vs. > 20%: 49%, p = 0.006) and p53-I (0/+: 56% vs. ++/ : 79%, p = 0.008). A significant prognostic impact on locoregional control was noted for the duration of RT (< or = 46 days: 86% vs. > 46 days: 68%, p = 0.01), tumor site (tonsils: 88% vs. soft palate: 67% vs. base of tongue: 51%, p = 0.02), Ki-67 LI (< or = 20% LI: 87% vs. > 20% LI: 56%, p = 0.018), and the p53-I (0/+: 58% vs. ++/ : 88%, p = 0.0006). On multivariate analysis, the p53 nuclear intensity (p = 0.002) and the Ki-67 index (p = 0.01) remained the only significant factors for locoregional control. CONCLUSION: Ki-67 labeling index above 20% and a weak p53 nuclear intensity (0/+) are both able to identify patients with squamous cell carcinoma of the oropharynx being at high risk for local recurrence after surgery and postoperative RT. Consequently, in this subgroup an intensification of treatment may be contemplated in prospective trials.

Middle ear adenocarcinoma with intracranial extension. Case report.

Middle ear adenocarcinoma is a very rare, locally invasive neoplasm assumed to arise from the middle ear mucosa. Although endolymphatic sac tumor (aggressive papillary middle ear tumor) and jugulotympanic paraganglioma may show brain invasion, intracranial extension of histologically confirmed middle ear adenocarcinoma has not been previously reported. The authors describe a 53-year-old man who suffered from otalgia and tinnitus for more than 10 years and from neurological deficits for 1 year due to a large temporal bone tumor that invaded the temporal lobe. A combined neurosurgical and otolaryngological resection was performed. Pathological analysis revealed a low-grade adenocarcinoma of a mixed epithelial-neuroendocrine phenotype, which showed a close histological similarity to, and topographical relationship with, middle ear epithelium. The authors conclude that middle ear adenocarcinoma belongs to the spectrum of extracranial tumors that have possible local extension to the brain.

Transoral laser surgery of supraglottic cancer: follow-up of 141 patients.

OBJECTIVE: To determine the role of transoral laser resection of supraglottic carcinomas. DESIGN: Retrospective unicenter study of the oncologic results of transoral carbon dioxide laser microsurgery for supraglottic carcinomas performed between February 1979 and December 1993. Median follow-up was 37 months. SETTING: University hospital academic tertiary referral center. PATIENTS: We reviewed the medical records of 141 patients (a consecutive sample of 131 men and 10 women; mean age, 60 years) with histologically proven supraglottic carcinomas undergoing transoral laser surgery, possibly in combination with neck dissection or radiotherapy. Stage distribution of patients was as follows: stage I, 23.4%; stage II, 25.5%; stage III, 16.3%; and stage IV, 34.8% (according to the Union Internationale Contre le Cancer staging system). MAIN OUTCOME MEASURES: Recurrence-free survival rates and local and regional recurrence rates. RESULTS: Five-year recurrence-free survival rates were as follows: the whole case load, 65.7%; stage I, 85.0%; stage II, 62.6%; stage III, 74.2%; and stage IV, 45.3%, according to the Union Internationale Contre le Cancer staging system. The local and regional recurrence rates were 16.3% and 9.9%, respectively. CONCLUSIONS: The oncologic results of transoral carbon dioxide laser surgery are satisfying if clean surgical margins (R0 resection) can be reached. In patients in whom tumor-free margins are not achieved (R1 and R2 resection) and transoral revision is not possible, transcervical procedures (partial or total laryngectomy) should be performed. The indication for transoral supraglottic laryngectomy in T3 lesions should be considered with restraint.

Endoscopic endonasal dacryocystorhinostomy: results in 56 patients.

Fifty-six patients with a complete stenosis of the nasolacrimal duct were treated by endoscopically controlled intranasal dacryocystorhinostomy according to West. Forty-four patients had idiopathic stenosis and 12 had posttraumatic scarring. Revision surgery was done in 11 of these 56 cases (8 patients with a previous external Toti procedure, and 3 patients with previous endonasal surgery). Altogether, 95% of the patients were symptom-free (86%) or felt improved (9%) postoperatively. Surgical revision was successful in 82%. Of patients with an "idiopathic" stenosis, 84% were healed and an additional 11% were improved. The success rate in the 12 patients with posttraumatic stenosis was 92%. Endoscopic duct surgery is a highly successful procedure with a low complication rate, the worst complication being persistence of symptoms.

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

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

[Experience with laryngotracheal reconstruction in subglottic stenosis in a 30 years time period]. / Erfahrungen mit der laryngotrachealen Erweiterung bei subglottischen Stenosen in einem Zeitraum von 30 Jahren.

BACKGROUND: Severe subglottic stenosis is a difficult condition to manage. It can be treated by laryngotracheal reconstruction or cricotracheal resection. PATIENTS AND METHODS: In this retrospective study the experiences for treatment of isolated subglottic stenosis in 37 patients (age: 3-78 years; stenosis grading: 20 x grade II, 13 x grade III, and 4 x grade IV) by laryngotracheal reconstruction in a 30-years experience are presented. RESULTS: In 33 out of 37 patients (89.2 %) a sufficient subglottic patency (postoperative endoscopic finding: stenosis less than 30 %) was achieved by laryngotracheal reconstruction. However, 5 patients of this series had required revision of laryngotracheal recontruction and in 22 patients endoscopic removal of granulation tissue had been performed. Sufficient widening of the subglottic space had been possible in all grade II stenosis (20/20), in 11 out of 13 patients with grade III stenosis, and in 3 out of 4 patients with grade IV stenosis. In one child an accidental decannulation occurred and due to asphyxia an apallic syndrome developed. CONCLUSIONS: Even through laryngotracheal reconstruction is a demanding surgical technique requiring great experience it is an effective option for treatment of subglottic stenosis less than 90 %. For severe subglottic stenosis (> 90 %) treatment by laryngotracheal reconstruction is possible and should be considered if mobilisation of the trachea by scar tissue is suited to be worse or to extended cricotracheal stenosis is present, both being not good candidates for cricotracheal resection.

[Styloid syndrome and its treatment]. / Das Styloidsyndrom und seine Behandlung.

BACKGROUND: An elongation of the styloid process or an ossification of the stylohyoid ligament can be the cause for a styloid syndrome and may lead to craniocervical pain, globus sensation and dysphagia. Pathophysiologically, the styloid syndrome is related to an irritation of the surrounding nerves, the carotid artery or the pharyngeal mucosa. There are various alternatives for its treatment. PATIENTS AND METHODS: This study analyzed retrospectively the data of eleven patients, who were treated for a styloid syndrome. All patients were placed on a stepwise therapy plan, which began with a medicamentous treatment, followed by a surgical treatment, if the problems persisted. The surgical approach included a transoral styloid fracture and/ or a surgical styloid shortening, which was carried out either transorally or transcervically. RESULTS: Three of the eleven patients presented no complaints after the medical treatment and did not require any further therapy. In two out of five patients, transoral fracturing of the styloid was successful. Six patients underwent surgical resection of the styloid process. In five cases a transoral route was used and in one cases a transcervical route. Postoperatively, four patients were free of symptoms and did not present any functional deficit. Two patients experienced severe complications with an ipsilateral medial cerebral artery infarction. These were related to a dissection of the internal carotid artery (ICA) in one case, and an arrosion bleeding of the ICA after the formation of an abscess of the parapharyngeal space in the other case. CONCLUSION: A stepwise therapy of the styloid syndrome including medicamentous treatment, transoral styloid fracture and resection of the styloid process has proven to be of value. If the styloid process can be palpated submucosally, a transoral resection may be chosen. However, using this route, the possibility of severe complications has to be taken into consideration, such as injury of the internal carotid artery.

[Juvenile nasopharyngeal fibroma. Report of experiences]. / Das juvenile Nasenrachenfibrom. Ein Erfahrungsbericht.

The juvenile nasopharyngeal angiofibroma is a rare and histologically benign tumour of the adolescent male. The aetiology and site of origin are unknown. The diagnosis can easily be made by the symptoms, the typical angiographic pattern and the endoscopic picture. Complete surgical extirpation is superior to all other modalities such as radiotherapy and hormonal treatment. To reduce the enormous blood flow into the tumour, the ligation of the external carotid artery, or the embolisation of the feeding vessels are the best presurgical methods. The technique of tumour removal differs according to the size of the tumour. A great therapeutic problem are those tumours which grow through the skull base and invade the sella, the optic nerve or the cavernous sinus. These tumours should be removed as radically as possible. Small areas of intracranial tumour could remain in order to preserve the optic nerve or the pituitary. These small areas respond very well to 4000 rads. Of 14 patients treated between 1972 and 1981, 12 tumours (types I and II) could be removed completely (recurrence rate 0%), 2 neoplasms ( typ III and IV) which were removed incompletely, received 4000 rads directed at the intracranial remnant, and showed no tumour progression within 4 and 6 years. The preoperative use of hormones (2 cases) showed no effect on the tumour size, especially not on intraoperative loss of blood.

[Therapy of lymphangioma in the head and neck region]. / Die Therapie der Lymphangiome im Kopf-Hals-Gebiet.

20 patients with a lymphangioma of the head and neck were observed after surgery over follow-up intervals of 3 to 13 years. In six children the tumor removal had to be subtotal in order to preserve vital organs. Though small areas of tumor were left no recurrent tumor growth was observed in this group. In 14 patients the tumor was surrounded by a capsule, in six newborns and children the tumor showed an infiltrating growth, which led to difficulties in breathing and swallowing. Out of the 14 radically operated patients, three had a recurrence after 1-2 years. In the six function conservating and not radical operated children, in whom small areas of tumor were left, no recurrence was noticed within 3-13 years.

[Closure of tracheo-esophageal fistulae after chronic intubation (author's transl)]. / Verschluss oesophagotrachealer Fisteln nach Langzeitintubation.

Tracheo-esophageal fistulae caused by prolonged intubation can be life-threatening to the patient involved. Older techniques for the closure of these fistulae were generally unsafe in infected tissues, were replete with complications, and had to be done in multiple stages. We describe a single-stage procedure for closure of posterior tracheal wall defects. A partially deepithelialized cervical flap is rotated between the sutured esophagus and the trachea. This reconstructed posterior wall is resistent to the presence of a cannula. In order to prevent recurrence of the fistula (if further respiratory treatment is needed), a small nasogastric tube or a long Penrose drain placed in the esophagus should serve as feeding tubes.

[The behavior of the facial nerve in vitamin A and thalidomide induced atresia auris congenita. A microsurgical and histological animal study (author's transl)]. / Das Verhalten des Fazialisnerves bei Vitamin A und Thalidomid-induzierter Atresia auris congenita. Eine mikrochirurgische und histologische Tierstudie.

Atresia auris congenita may include either a complete or incomplete paralysis of the facial nerve as well as a possible abnormal course of its tympanic segment. Pregnant Wistar rats were given high doses (50,000, 80,000 or 100,000 USP units) of vitamin A and (10,15 or 20 mg) Thalidomide on the 8th, 9th, 10th and 11th days of gestation. The animals were then sacrificed, and the temporal bones and the medulla oblongatas of the fetuses and the adult rats were examined microsurgically and histologically. In contrast to previous reports in the literature, no significantly abnormal courses of the nerve could be found. These findings corresponded to those of 62 endaurally operated human ear malformations. The paralysis of the facial nerve in these patients seems due to a reduced diameter of the nerve and not to a malformation of its nucleus.

[Lethal aspergillosis of the paranasal sinuses (author's transl)]. / Letale Aspergillose der Nasennebenhöhlen

A 73-year-old farmer developed both blindness of his left eye and a 20 kg loss of weight within 3 months. A protrusion of his left eyebulb was observed, which suggested the retrobulbar growth of a tumor. Histologic examinations of several biopsies from the paranasal sinuses evidenced polypoid tissue with signs of chronic inflammation, ulceration, and fungus infection. The patient died in cerebral coma. The autopsy revealed a destruction of the cranial base by a chronic mycocenic osteomyelitis, a frontal lobe abscess, and a fungus invasion of the internal carotid artery with circumscribed thrombosis of this vessel and adjacent encephalomalazie. The fungus was identified morphologically as aspergillus, a rare differential diagnosis to paranasal malignancies.

[Flap-reconstruction in mouth and oropharynx. A clinical comparison of methods (author's transl)]. / Lappenplastiken im Mund and Oropharynx. Ein klinischer Vergleichsbericht.

The possible methods for plastic reconstruction after resection of malignant tumors in the mouth and oropharynx are reported. A total of 165 patients, operated upon between 1973 and 1980, has been reviewed. The tumor was located 26 times in the tongue, 4 times within the base of the tongue, 27 times in the floor of the mouth, 10 times in the floor of the mouth and in the tongue and 80 times in the tonsils. For reconstruction 8 times the deltopectoral flap, 51 times the forehead flap, 42 times the tongue flap, 7 times the myocutaneous sternocleido-mastoideus island flap were used. 8 times other methods were applied, like for instance skin grafts, and in 41 cases a primary closure of the defect was possible. Complete necrosis of the flap were rare, more frequent in contrast were partial dehiscences with or without a fistula. Thus in the forehead flap 5 times a necrosis occurred whereas in 15 cases a dehiscence was seen. Even better results were achieved for the deltopectoral- and tongue flap. In contrast, the skin island of the myocutaneous sternocleidomastoideus flaps all became necrotic, but only once a temporary fistula developed. Of the pectoralis myocutaneous island flaps the first two became necrotic, probably due to lack of surgical experience. Taking into account the surgical expenditure, the functional as well as cosmetical results, the methods may be scaled according to clinical value as follows: The pectoralis major myocutaneous island flap and the tongue flap equally range on the first place, followed by the myocutaneous sternocleidomastoideus island flap, and on the 3. and 4. place by the deltopectoral and forehead flap.

[The treatment of tracheal stenosis by segmental resection (author's transl)]. / Segmentresektion zur Behandlung der zervikalen Trachealstenose.

In the past we treated most tracheal stenoses by creating a temporary open groove with subsequent reconstruction. This method has led to unsatisfactory results in some cases and has the disadvantage of a long duration of treatment. Therefore, we replaced it by segmental resection of the trachea with an end to end anastomosis. During the last 5 years 16 patients between 28 and 57 years of age with scar stenosis or malacia of the trachea have been operated successfully. In 12 patients a tracheostomy or an open groove were present and were included in the resection 11 times and left in place once. The tracheal defects resulting from resection were of a length of 1--5.5 cm. They could in all cases be bridged by mobilization of the trachea, upper laryngeal release and fixation of the head in a flexed position. The respiration is normal in 14 patients while 2 show a slight impairment. We conclude that because of the good functional results and the short duration of treatment (maximally 3 weeks) transverse resection of the trachea with an end to end anastomosis should be preferred over other operative procedures in the therapy of tracheal stenosis.

[Preservation of a vertical mucosa strip for one stage gullet reconstruction after radical resection of the pharynx and larynx (author's transl)]. / Einzeitiger Speisewegaufbau nach radikaler Larynx-Pharynx-Resektion mit erhaltenem Schleimhautstreifen

17 out of 22 patients with a squamous cell cancer of the Hypopharynx (T2-T4,N1-N3) are treated by resection of the pharynx and larynx, combined with radical neck-dissection on both sides, total strumectomy and full course of radio-therapy, reaching from the base of the skull down to the madiastinum. For the immediate reconstruction of a nutritional pathway the preservation of a vertical tumor free strip of the pharyngeal wall at least 15 mm broad is recommended. The remaining mucosa resected at least 20 mm from the margin of the tumor, and the edges controlled by frozen sections can be sutured over a nasal gastric tube of 18 or 16 charr. The reconstruction has several advantages. Though the observation time of 15 months is short, the recurrence rate seems not to be higher than after total resection of the pharynx and larynx.

Recurrent basal cell carcinoma of the facial region -- a clinico-pathological challenge.

The observation that the majority of patients with basal cell carcinomas of the face presenting for surgical treatment did previously have radiotherapy or have undergone inadequate excision due to cosmetic considerations of the surgeon, induced us to review our own case material. According to this reassessment, a concept of radical removal was developed which took particular account to the direction of growth of basal cell carcinoma into the depth. Of considerable importance seems to be the unequivocal marking of the excised material prior to its histological work up and the additional removal of sub-focal specimens for separate histological examination.