[Thyroid nodules ­ how to proceed?]. / Knoten in der Schilddrüse - wie weiter?

Asymptomatic thyroid nodules are very common and detected with increasing frequency by radiological investigations of the neck as so-called "incidentalomas". If a thyroid nodule is found, the question arises how to proceed with this case. The goal is to recognize the very rare malignant nodules and to perform an adequate therapy. Every work-up of a thyroid nodule includes functional evaluation by determination of thyroid stimulating hormone (TSH). Is the level of the hormone suppressed, a scintigraphy is indicated to rule out a hot thyroid nodule implying a benign finding. Ultrasound is the imaging of choice for the thyroid gland and provides information with respect to size, number and configuration of the nodes. Depending on sonographic evaluation and other possible risk factors, a fine-needle aspiration biopsy of the node is performed. Based on the cytologic findings further therapeutic procedures are determined.

Zenker's diverticulum: outcome of endoscopic surgery is dependent on the intraoperative exposure.

The purpose of the present study is to evaluate long-term outcome and patients' satisfaction after endoscopic therapy of Zenker's diverticulum (ZD) and to analyze the results of the stapler technique in comparison with the application of the carbon dioxide (CO2) laser. A retrospective cohort study with outcome analysis of patients undergoing endoscopic cricopharyngeal myotomy with either stapler or CO2 laser between October 2000 and December 2010 by a single surgeon was performed. Patient's medical charts were reviewed with respect to symptoms before intervention, intra and post operative complications, reasons for the choice of endoscopic technique, and postoperative relief of symptoms. Long-term follow-up was acquired by a standardized self-assessment questionnaire. Seventy-four patients (51 men, 23 women) with a median age at operation of 74 years (range 45-93 years) were enrolled in this study. Forty-five patients underwent endoscopic repair of a ZD with stapler, 29 patients with CO2 laser. The mean follow-up was 4.7 years. We did not observe significant differences for intra and post operative complications, hospital stay, time until normal oral food intake, need for revision, and long-term subjective symptom relief between the two groups. Overall complication (12 %) and recurrence rate (11 %) for the endoscopic techniques were low. Endoscopic surgery had also a high success rate in recurrence cases (87.5 %). According to our study, the most important factor for the success rate of endoscopic treatment was the intraoperative exposure of the ZD. The endoscopic minimally invasive approach is a safe and effective treatment modality and can be considered as the treatment of choice for primary and recurrent ZD. The intraoperative exposure is decisive for the technique applied and the long-term success.

[The treatment of epistaxis]. / Die Behandlung des Nasenblutens.

Epistaxis is one of the most common ENT emergencies and highly prevalent in the general population. Most cases are self-limiting and patients do not usually seek medical attention. However, some cases can be severe and life-threatening. While most anterior bleeds can be effectively managed by simple measures, including pressure application, vasoconstrictive agents and cautery, some will require additional measures such as nasal packing. Posterior epistaxis can be difficult to control. Latest studies showed that surgical ligation of the sphenopalatine and/or anterior ethmoidal arteries is the most effective treatment and less painful and distressing than nasal packing. But packing is the therapeutic option that is readily available.

An unusual complication of epistaxis: cerebral abscess formation after anterior ethmoidal artery ligation.

Epistaxis is a very common emergency in otorhinolaryngology. Anterior ethmoidal artery ligation using an external approach is one of the surgical options in posterior epistaxis. We present, to the best of our knowledge, the first reported case of an intracerebral abscess after epistaxis treatment with ligation of the anterior ethmoidal artery using an endoscopic-assisted external approach in a 56-year-old patient. The patient presented 4 days postoperatively with an orbital cellulitis. A CT was performed and a frontobasal hypodensity was found. An additional MR tomography the next day showed a lesion suspicious for an intracerebral abscess. Despite intravenous antibiotic therapy, the lesion increased and was successfully treated by the neurosurgeons, with abscess resection over a craniotomy and frontobasal repair using a pedicled periosteal flap. Surgeons have to be aware of this rare but possibly lethal severe complication and should consider early imaging studies, especially if a periorbital cellulitis appears.

Expression of Melan-A/MART-1 in primary melanoma cell cultures has prognostic implication in metastatic melanoma patients.

The lack of melanoma-associated antigen (MAA) expression has been associated with the reduced overall survival in melanoma patients. In order to investigate whether the MAA expression detected on cell cultures established from melanoma patients might relate to the overall survival in these patients, we screened primary cell cultures derived from 37 melanoma metastases for the expression of five known MAA: Melan-A, tyrosinase, gp-100, MAGE-1 and MAGE-3 by polymerase chain reaction (PCR) and fluorescence-activated cell sorting (FACS). MAA expression detected by PCR was found at a high percentage in evaluated melanoma cell lines: 25 of 28 (89%) were positive for Melan-A, 22 of 28 (79%) were positive for tyrosinase, 26 of 28 (93%) were positive for gp-100, and 18 of 28 (64%) were positive for MAGE-3 expression. Using the FACS method the percentage of MAA-positive cell lines was much lower: 14 of 31 (45%) cell lines were positive for Melan-A, eight of 31 (26%) were positive for tyrosinase, 13 of 31 (42%) were positive for gp-100, six of 31 (19%) were positive for MAGE-1, and 14 of 31 (45%) were positive for MAGE-3 expression. Kaplan-Meier survival analysis demonstrated that the patients whose cell lines were positive for Melan-A expression by PCR had significantly longer overall survival time as Melan-A PCR-negative cases (P=0.0038). This could not be shown for any of the markers tested by FACS. Our results suggest that the expression of Melan-A/MART-1 in patient-derived cell cultures may help to identify a group of melanoma patients with prolonged survival.

THREAT helps to identify epistaxis patients requiring blood transfusions.

OBJECTIVE: To analyze the characteristics of patients who needed a blood transfusion due to epistaxis-caused anemia and to define potential risk factors. DESIGN: Retrospective cohort study. SETTING: A total cohort of 591 epistaxis patients, prospectively included between March 2007 and April 2008 at the ENT department of the University Hospital of Zurich, was evaluated concerning the need for blood transfusions. METHODS: The clinical charts and medical histories of these patients were evaluated. MAIN OUTCOME MEASURES: Common parameters that increase the risk for severe anemia due to epistaxis. RESULTS: Twenty-two patients required blood transfusions due to their medical condition. 22.7% suffered from traumatic nosebleeds. Another 27.3% had a known medical condition with an increased bleeding tendency. These proportions were significantly higher than in the group of patients without need of blood transfusion. The odds ratio for receiving a blood transfusion was 14.0 in patients with hematologic disorders, 4.3 in traumatic epistaxis and 7.7 in posterior bleeders. The transfusion-dependent epistaxis patients suffered significantly more often from severe posterior nosebleeds with the need for a surgical therapeutic approach. CONCLUSIONS: Patients with severe nosebleeds either from the posterior part of the nose or with known hematologic disorders or traumatic epistaxis should be closely monitored by blood parameter analyses to evaluate the indication for hemotransfusion. The acronym THREAT (Trauma, Hematologic disorder, and REAr origin of bleeding → Transfusion) helps to remember and identify the factors associated with an increased risk of receiving blood transfusion.

Comparison of morbidity between sentinel node biopsy and elective neck dissection for treatment of the n0 neck in patients with oral squamous cell carcinoma.

BACKGROUND: Sentinel node biopsy (SNB) has been proposed for staging of the cN0 neck in early oral/oropharyngeal squamous cell carcinomas (SCC). Because SNB is a minimally invasive procedure, it is thought to be associated with less morbidity than elective neck dissection. METHODS: Sixty-two consecutive patients were included from 2000 to 2009. Two groups were analyzed consisting of 33 patients after SNB and 29 after elective neck dissection. Subjective impairment and functional shoulder status were assessed with the Neck Dissection Impairment Index (NDII) questionnaire and the modified individual relative Constant Score. Postoperative complications were retrieved from the clinical charts. RESULTS: The investigated scores were significantly better in the SNB group. All postoperative complications occurred in the elective neck dissection group. CONCLUSION: SNB is associated with significantly less postoperative morbidity and better shoulder function than elective neck dissection. This supports our opinion that patients with nodal negative early SCC of the oral cavity should be offered SNB.