[The new S2k AWMF guideline for the treatment of obstructive sialadenitis in commented short form]. / Die neue S2k AWMF Leitlinie zur Behandlung der obstruktiven Sialadenitis in kommentierter Kurzform.

A new and interdisciplinary S2k AWMF guideline for the treatment of obstructive sialadenitis has been published. There have been several technical achievements, for instance in the field of ultrasonography, via sialendoscopy, or by MR-sialography, that have increased the possibilities for diagnosis and treatment of patients with obstructive sialadenitis. In the past, the treatment of choice in case of unsuccessful medical treatment was a complete extirpation of the affected salivary gland. Nowadays, using a variety of modern treatment options (like sialendoscopy, or extracorporeal shock-waves lithotripsy sometimes combined with salivary duct incision), it is possible in most patients, especially in cases of sialolithiasis, to preserve the affected gland. A functional recovery after gland-sparing surgery is described but more data is needed to finally evaluate the long-time results. The new guideline describes all relevant steps to diagnose an obstructive sialadenitis and values all diagnostic tools critically. Finally, all recommendable therapy options are described and valued, too.

[Viral sialadenitis]. / Virale Speicheldrüsenentzündungen.

Beside a secondary, clinically latent salivary virus secretion, differentiation can be made between concomitant sialadenitis induced by various viruses and viral sialadenitis showing characteristic and/or pathognomonic morphological and clinical features, whereby sialadenotropism must also be present. Viremia induces a viral inflammatory reaction via a local cytopathogenetic effect. Clinically important viral diseases include epidemic parotitis (mumps), cytomegaly and HIV infection presenting with large lymphoepithelial cystic lesions.

A comparative study of sonographic and histopathologic findings of tumorous lesions in the parotid gland.

OBJECTIVE: The purpose of this study was to clarify which histopathologic features are visualized on sonograms by comparing sonomorphologic and histopathologic analyses of parotid tumorous lesions on the same plane. STUDY DESIGN: Boundaries, shapes, echo intensity level, distribution of internal echoes, and acoustic enhancement on sonograms of 86 parotid tumorous lesions were retrospectively compared with the histopathologic findings. RESULTS: Unclear boundaries on sonograms corresponded to abundant connective tissue with scattered tumor cell nests. Polygonal shapes on sonograms were revealed to represent tumor cell infiltration on histopathologic sections. The "very hypoechoic" lesions showed significantly high ratio of cystic areas (P < .05) in Warthin tumor. The weakly hyperechoic structures on sonograms were connective tissue, hyaline, and necrotic and keratinized materials. Attenuated posterior echoes were observed in malignant tumors with abundant connective tissue and metaplastic bone formation. CONCLUSIONS: To facilitate correct sonographic diagnosis, it is important to ascertain the correlation between sonomorphology and histopathology.

Statistical study for sonographic differential diagnosis of tumorous lesions in the parotid gland.

OBJECTIVE: The purpose of this study was to clarify characteristic sonomorphologic features of parotid lesions statistically and to propose new criteria for the differential diagnosis. STUDY DESIGN: Eighty-six tumorous lesions were analyzed with regard to the following sonomorphologic features: boundary, shape, echo intensity level, distribution of internal echoes, and acoustic enhancement. Stepwise polychotomous logistic regression analysis was performed to assess characteristic sonographic features. As dependent variables, we used "pleomorphic adenoma," "Warthin tumor," "malignant tumors" and "other benign lesions"; as predictor variables, we used the aforementioned sonomorphologic features. Proportion of the occurrence of each dependent variable was calculated. RESULTS: Lobular shape and homogeneous internal echoes predicted pleomorphic adenoma. A lesion with multiple anechoic areas would be Warthin tumor with very high sensitivity. Malignant tumors showed either heterogeneous internal echoes without characteristic structures or polygonal shape. CONCLUSIONS: These sonomorphologic features should be observed to make more exact differential diagnoses for operation and therapy planning.

Sonographic analysis of recurrent parotitis in children: a comparative study with sialographic findings.

OBJECTIVE: The sonographic features of recurrent parotitis in children were studied to clarify a relationship between sonographic and sialographic findings in this disease. STUDY DESIGN: Twenty-one glands (7 on follow-up) were examined by 7.5 MHz ultrasonography and sialography. Echo intensity level, distribution of the internal echoes, and size of hypoechoic areas were compared with the size of punctate shadows on the sialograms. Twenty other histopathologic specimens were analyzed to investigate the entity of hypoechoic areas. RESULTS: Sonography showed hypoechoic, heterogeneous internal echoes, the level of which increased as the punctate shadows enlarged. Hypoechoic areas, all of which were larger than the sialographic punctate shadows, were observed in 62% of the glands. Histopathologic analysis suggests that these hypoechoic areas represent dilated peripheral ducts with lymphocytic infiltration. Sonography was likely to detect changes over time more sensitively than sialography. CONCLUSIONS: Sonography should be performed as the test of first choice, both in the primary and follow-up stages, in cases of recurrent parotitis in children.

The clinical presentation of non-hodgkin lymphomas of the major salivary glands.

The aim of this study was to examine the clinical presentation of patients with malignant lymphoma of the major salivary glands. In a retrospective study, 26 patients with a non-Hodgkin lymphoma (NHL) of the major salivary glands were examined. The results showed a distinct preference for the female gender. Two groups with clinical differences were observed depending on lymphoma manifestation as either extranodal-parenchymal (extranodal) or with intra- or periglandular (nodal) lymph node disease. Differences between these two groups existed with regard to the length of clinical history, recurrent vs continuously progressing symptoms and presentation on ultrasound examination (multiple masses compared to solitary masses). Patients with an extranodal lymphoma always showed disease limited to the affected gland, whereas those patients with a nodal lymphoma presented with stage II or higher (Ann Arbor Classification). In these patients, local recurrence was also five times higher (5/13; 38.4%) than in patients with an extranodal lymphoma (1/13; 7.7%). In 1 patient (7.7%) with extranodal lymphoma, dissemination was observed, compared to 6/13 patients (46.2%) in the group with nodal disease. Seven out of 13 patients (53.8%) with nodal disease died due to lymphoma spread and 1/13 (7.7%) of the patients with extranodal disease. There seem to be distinct clinical differences in the course of patients with NHL of the major salivary glands, depending on extranodal or nodal disease presentation. The histopathological diagnosis, with special recognition of the particular lymphoma pathogenesis, constitutes an important prognostic factor in these patients.

[Transposition flaps for reconstruction of deep defects of the medial eyelids. Fasciocutaneous rotations- and transposition flaps and modified pure fascial transposition flap]. / Transpositionslappenplastiken zur Rekonstruktion von tiefen Defekten des medialen Lidwinkels. Fasziokutane Rotations- und Transpositionslappenplastik und fasziale Transpositionslappenplastik.

Tumor resection in the medial canthal area may result in deep defects with involvement of the ethmoidal bone and destruction of the lacrimal ducts. While shallow defects with little involvement of bone can be covered with the classic glabellar flap, deep defects require larger fasciocutaneous flaps from the forehead that can also be used for the reconstruction of the involved medial parts of the eyelids. The preferred techniques of the median or paramedian transposition flaps and a modified paramedian fascial flap for reconstruction of the medial orbital wall and support of the orbit are described.

[Experimental determination of the time-dependent extent of after-burning with reference to possibilities of the plastic surgery reconstruction of 3d degree burns]. / Experimentelle Feststellung des zeitabhängigen Ausmasses des Nachbrennens im Hinblick auf die Möglichkeit der plastischen Deckung drittgradiger Verbrennungen.

The present experiments try to answer the question as to the time-dependent extent of the after-burning process after full-thickness burn (third degree). For an early plastic surgical treatment it was of interest to determine the most early time of escharotomy. The time-dependent spreading of the after-burning area reached its maximum five days after the burn injury. The after-burning area was marked by intravenous injections of Patentblau which caused distinct intravital colouring. Subsequently no further progress could be observed. In the present experiments we suggest this time as the earliest time for plastic covering in case it would be dependent upon the end of the after-burning process.

Updated S2K AWMF guideline for the diagnosis and follow-up of obstructive sialadenitis--relevance for radiologic imaging.

The interdisciplinarily developed German S2k AWMF guideline for the treatment of obstructive sialadenitis represents a new standard in the guideline program of the AWMF, the German Society for Consultants and the clinical disciplines working in the field of diseases of the head and neck region. In the last few years new diagnostic and therapeutic possibilities have been established in obstructive chronic Sialadenitis offering individually optimized therapeutic strategies. Only a few years ago extirpation of the whole affected gland was the only relevant therapy option. Nowadays therapeutic options such as interventional sialendoscopy and extracorporeal shock-wave lithotripsy (ESWL) are available in combination with marsupialization or incision of the duct. If possible the focus is on preserving the main glandular duct. In the following article the relevant aspects for the diagnostic radiologic procedures are presented.

Benign and malignant salivary gland diseases in children A retrospective study of 549 cases from the Salivary Gland Registry, Hamburg.

OBJECTIVE: Tumors of salivary glands in children are rare. Basically all types of salivary gland diseases during the period of childhood are described. The incidences of salivary gland tumors in children (0-14 years) differ completely from those in adults. Especially the malignant neoplasms are very rarely described in literature. Only some collective reviews and case reports try to summarize frequency, distribution concerning sex and age, morphology and localization. METHODS: In our study we were able to draw data from the Hamburg Salivary Gland Registry, concerning the last 25 years regarding histopathological diagnosis, age, gender and localisation of the pathologies. Findings were compared to other studies. Most of the specimens were presented by the Clinic for Otorhinolaryngology and Head and Neck Surgery, University Hamburg, Eppendorf. As a reference centre for salivary gland diseases some material was sent by other institutions. RESULTS: This study will give a detailed survey of salivary gland diseases and tumors in children up to the age of 14 which have undergone surgical therapy/biopsy. We present the general distribution of the different tumors/diseases, the distribution in certain age groups and the various locations. 549 cases could be examined. Comparing the distribution of malignant tumors with other studies, the epithelial-myoepithelial carcinomas followed by salivary duct carcinomas represent the largest group in childhood. CONCLUSIONS: The study shows that comparing to adulthood different tumors play an important role in adolescence. The distribution of tumors in childhood may help in diagnostic. Further many salivary gland diseases in childhood underwent surgery/biopsy although this is not supposed to be the proper treatment. The study shows that the right diagnosis most often can only be reached by surgery and histology.

[Clinical diagnosis of salivary gland sarcoidosis (Heerfordt syndrome)]. / Zur klinischen Diagnostik der Speicheldrüsensarkoidose (Heerfordt-Syndrom).

Sarcoidosis, a systemic granulomatous disease of unknown cause, may involve any body organ. The most common manifestation in the head-neck area is lymph node sarcoidosis or, alternatively, Heerfordt's syndrome (with involvement of lacrimal and parotid gland and possible facial palsy). Far less common is a isolated laryngeal sarcoidosis. The typical histopathological appearance proves the diagnosis. However, obtaining representative and sufficient biopsy material in some cases may carry risks for the patients or might technically be difficult. In these cases, the clinician can fall back on two other, noninvasive diagnostic procedures: ACE level activity determination in blood serum and 67gallium citrate scintigraphy. Elevated ACE levels in combination with a positive 67gallium scintigraphy have a specificity (combined) of 99%. As a valuable side effect, this procedure sensitively may discover additional disease in the body and also serves well as a therapy-control examination. The presented case report shows clearly that these clinical methods, if combined, are sufficient for diagnosis of Heerfordt's syndrome/sarcoidosis; no additional histopathological examination is required.

[Intramuscular hemangioma of the posterior wall of the pharynx. Diagnosis and differential diagnosis]. / Intramuskuläres Hämangiom der Rachenhinterwand. Diagnose und Differentialdiagnose.

We report on the case of a seven-year old boy who developed an enlarged swelling of the oropharynx. Clinical examination revealed a well demarcated cystic tumour. Histopathologically the diagnosis of an intramuscular haemangioma could be made because of the multitude of vascular spaces filled with erythrocytes lying between bundles of smooth muscles. Such a lesion coming from the posterior wall of the oropharynx is not described in literature. In differential diagnosis the angiosarcoma and the arteriovenous aneurysm must have been involved since there were multiple arteries and veins lying close together in couples. Moreover the adenotomia carried out one and a half year earlier prompted us to think about the possibility of a traumatic arteriovenous fistula.

[Clinical, histopathologic and immunohistochemical studies of chronic sialectatic parotitis in childhood and adolescence]. / Klinische, histopathologische und immunhistochemische Untersuchungen zur chronischen sialektatischen Parotitis im Kindes- und Jugendalter.

UNLABELLED: Chronic sialectatic parotitis (CSP) causes problems in differential diagnosis and therapy. CSP shows the typical clinical features of chronic recurrent parotitis and will be investigated histopathologically only after ultimative parotidectomy. The etiology and pathogenesis of these unspecific inflammations is still unknown. Therefore no causal therapy is available and a lot of different trials (sialogoga, gland massage, infrared light, antibiotics, antiphlogistics, Trasylol, duct occlusion, duct ligation, gland denervation, radiotherapy) are not successful in the long run. MATERIAL AND METHOD: The salivary gland registry of the University of Hamburg (1965-1996) contains 22 infants and juvenile patients showing very severe courses of CSP. These cases have been investigated clinical (ultrasound, sialography), histopathological (paraffin embedded sections, histomorphometry of the ectatic duct lumina) and immunohistochemical (CK-MNF, AKTIN, KiM4) in a retrospective study to research the pathogenesis of CSP. RESULTS: Recurrent and always very dolent parotid swelling occurs between the age of 3 and 14 years for the first time. The courses vary from 3 months until 25 years. Local findings as well as ultrasound and sialographic features allow no certain differentiation of chronic recurrent parotitis. Conservative therapy fails in each case and leads to the necessity of surgical treatment. Histopathological three different stages of development can be observed: Initial stages show regular lobular architectonic structure of the parotid gland parenchyme with duct ectasies surrounded by slight inflammation of lymphocytes and plasmacells. Advanced stages are characterized by an increase of periductal inflammation and the appearance of lymphfollicels. Nearly complete lymphatic transformation of the parenchyme with destruction of the lobular formation dominates the terminal "immunologic" stage. Some cases show multiple myoepithelial islands within this lymphatic stroma typically observed in benign lymphoepithelial lesions. Whether bacteria nor primary obstructive changes can be observed. The histomorphometric analyses of the average and maximal luminal duct diameters show marked increase of 39% respectively 46% from and- vanced to terminal stages of CSP. Therefore the pathognomonic duct ectasies seem to depend on the progredient inflammation and are not due to a hereditary malformation of the duct system. Immunohistochemical terminal stages show follicular lymphatic hyperplasia (KiM4) expressing overshooting humoral immune reaction of MALT. CONCLUSION: Concerning the pathogenesis CSP corresponds to a immunopathological disorder of MALT and seems to be a prestage of benign lymphoepithelial lesion. Consequently important changes in the diagnosis and therapy of CSP lead to early histopathological investigation to differentiate the stage of inflammation. In stage III conservative parotidectomy should be carried out because spontaneous healing can not be expected. In contrast initial cases should be treated at first by glucocorticoids and immunosuppressives.

[Histopathogenesis of chronic sialectatic parotitis as precursor of myoepithelial sialadenitis lesion (Sjögren syndrome)]. / Zur Histopathogenese der chronischen sialektatischen Parotitis als Vorstufe der MESA (Sjögren-Syndrom).

BACKGROUND: Chronic sialectatic parotitis (CSP) is classified as a characteristic form of chronic recurrent parotitis the etiology and pathogenesis of which still remains unclear. The multiplicity of different therapeutic advices, especially the permanent failure of antibiotic treatment, underlines the lack of an appropriate causal therapy. CASE REPORT: Detailed histopathological investigations of an 41-year old woman were possible over a seven-year period. These follow-up observations enabled clarification of the histopathogenesis of CSP by means of immunohistochemistry. RESULTS: During the course and development of CSP different stages can be observed: The initial phase is characterised by mild infiltration of B-lymphocytes (CD20, CD45 R) and plasma cells in the environment of ectatic ducts. Progredient stages show neogenetic lymph follicles periductular as well as metaplasia of the ductal epithelium. Terminal phases of CSP are characterised by near-total lymphatic transformation of parenchyma, follicular lymphatic hyperplasia (KiM4) and myoepithelial proliferation. In this phase myoepithelial sialadenitis (MESA, i.e. benign lymphoepithelial lesion, possibly part of Sjögren's syndrome) develops. Beyond it low grade non-Hodgkin's lymphoma of the MALT-Type of the submandibular gland occurred finally. CONCLUSIONS: CSP presents as a precursor of MESA. Immunohistological detection of follicular dentritic network (KiM4) within extensive lymphatic hyperplasia periductular demonstrates overshooting humoral immune reaction of B-lymphocytes. Hence, CSP should be classified with regard to pathogenesis as an immunopathological disorder of the MALT system.

[Clinical aspects and therapy of extratemporal facial neurinoma]. / Zur Klinik und Therapie des extratemporalen Fazialisneurinoms.

BACKGROUND AND OBJECTIVE: Extratemporal facial nerve neurinomas are rare. In the present study, the epidemiology, clinical presentation and in particular surgical treatment of this entity was analysed under special focus on facial nerve preservation. PATIENTS/METHODS: 22 patients with an extratemporal facial nerve neurinoma of the parotid gland, treated at the University-ENT-Clinic Hamburg-Eppendorf during 1977-1997 were analysed retrospectively. RESULTS: All patients presented with a unilateral parotid mass, on ultrasound examination regularly an encapsulated intraparotideal tumor. 16 patients (72.7%) had regular facial nerve functioning. 6 patients (27.3%) with partial or complete peripheral facial nerve paralysis were treated with partial or radical parotidectomy because of malignancy possibility. In the group of patients with intact facial nerve, latero-facial (superficial) parotidectomy with segmental nerve resection was undertaken in 9 cases (56.3%) because nerve-continuity was not siezable within the tumor area. In 7 cases (43.7%), tumor-enucleation was feasable with complete nerve preservation. Intraoperative frozen section in a total of 4 (18.2%) patients always showed the correct histopathological diagnosis. No tumor-recurrence was observed in the 15 cases (68.6%) which underwent follow-up. CONCLUSIONS: In case of extratemporal neurinoma of the parotid gland, preparation of the facial nerve during surgery is often impossible, leading to segmental nerve resections. This decision, however, is made without proof for malignancy. In recognition of the biological behaviour of this entity the authors recommend that after tumor exploration a biopsy should be taken from the periphery of the tumor to exclude malignancy. After diagnosis of a neurinoma a nerve preserving (wait-and-see) approach appears justified.

[Site and epidemiology of mucoepidermoid carcinoma. Analysis of 327 cases]. / Untersuchungen zur Lokalisation und Epidemiologie des Mukoepidermoidkarzinoms. Analyse von 327 Fällen.

The salivary gland registry of the University of Hamburg (1965-1992) comprises a total of 327 mucoepidermoid carcinomas (MEC). MEC occur between the age of 5 and 96 years, most frequently in the sixth and seventh decade of life. The average age lies below 50 years (48.9 years). There is a slight predisposition of females (56.3%). Nearly 60% of all MEC care localised in the major salivary glands. The parotid gland is the most frequent localisation (53.5%) followed by the palate (17.4%). MEC are less frequent in the submandibular and sublingual glands, such as the minor salivary glands of the oropharynx and the cavity of the mouth. 53.2% of all MEC's can be classified as highly differentiated, the remaining 46.8% as poorly differentiated. MEC's of the palate are predominantly highly differentiated (72.0%). Among the variants of MEC, cystic (25.4%), clear cell (11.0%) and oncocytic (0.6%) tumours can be observed. MEC's of the clear cell type tend to originate from minor salivary glands (69.5%). MEC of childhood and adolescence (8.6%) are preferably seen in the parotid gland (46.4%) and the palate (39.3%). Up to the 20th year of life, cystic tumours and tumours of the clear cell type are comparatively more frequent.

[Histology of mucoepidermoid carcinoma. Analysis of 327 cases]. / Ein Beitrag zur Histologie des Mukoepidermoidkarzinoms. Analyse von 327 Fällen.

The mucoepidermoid carcinomas of the salivary glands (MEC) show histologically a wide spectrum of differentiation from solid epidermoid tumours to cystic mucous-filled tumours. Epidermoid cells, mucous cells and intermediate cells are the main cellular components. Besides clear cell (11.0%) and oncocytic (0.6%) variants and "cystic" (25.4%) tumours can be observed. According to the per cent of mucous cells and cystic spaces of the total tumour mass different degrees of histomorphologic differentiation can be distinguished. Therefore highly differentiated MEC (53.2%) with more than 50% mucous cells and cystic spaces, respectively low-differentiated MEC (46.8%) showing less than 50% mucous cells and cystic spaces can be subclassified. In respect of the therapeutic proceeding it should be recognized that the histopathological subclassification of MEC of the salivary glands (7) is based on morphological criteria only. It may not be equalized with a grading of malignancy since even highly differentiated MEC can grow infiltratively, sometimes osseo-destructively, to recur locally and to metastasize predominantly into the regional lymph nodes. Consequently the histopathological subclassification of MEC does not allow certain prognosis in individual cases.

[First results of the wave-guide in CO2-laser surgical reduction of the hyperplastic nasal turbinates]. / Erste Anwendungsergebnisse des Wave-Guide bei der CO2-laserchirurgischen Verkleinerung der hyperplastischen Nasenmuscheln.

BACKGROUND: The CO2-laser-surgical reduction of the hyperplastic nasal turbinates represents a standard procedure in ENT-Surgery. In the presented paper, the authors introduce a new technique for the treatment of hyperplastic turbinates. METHODS: The laser beam is transmitted through a 90 degrees handpiece to the mobile "infra-guide" wave guide, which contains a 1 mm ceramic tube. By application of mirrow pieces with different angles, laser surgical reduction of those parts of the nasal turbinates is possible, which normally can not be reached by conventional, tangentially to the mucosa directed laser beams. The direction of the laser beam is controlled either optically, as in endonasal sinus surgery, or monitored through a camera. A total of 36 patients (22 women, 14 men, mean age 32.7 years) with nasal turbinate hyperplasia and either impaired nasal breathing and/or retronasal drip were treated with the new method. RESULTS: The laser wave guide represents a minimally invasive and basically complication-free method feasable on an outpatient basis. As a particular advantage, laser surgical reduction of the posterior parts of the inferior and also the middle turbinate is possible. The majority of the patients relates of an improvement of the preoperative symptoms (regarding reduction of impaired nasal breathing: 61.3 %, regarding reduction of post nasal drip 87.1 %). CONCLUSION: The laser wave-guide represents a basically complication-free, minimally invasive supplement to the different treatment modalities of the hyperplastic nasal turbinates.

[Clinical aspects and histopathology of middle ear tuberculosis]. / Ein Beitrag zur Klinik und Histopathologie der Mittelohrtuberkulose.

During the past few decades the clinical features of middle ear tuberculosis have changed. Hence, clinical differentiation between tuberculous and non-specific proliferative otitis media and mastoiditis is now difficult. Between 1986 and 1992 five cases of tuberculous otitis media were treated surgically in the ENT-Dept. of the University of Hamburg, representing 0.2% of all performed middle ear operations. According to our experience the therapy of choice is the open mastoid cavity with subsequent chemotherapy to avoid recurrent infections. The advantages of this procedure are proven by actual histopathological findings as well as by the analysis of historical microsections of the Wittmaack temporal bone collection: according to these findings, two different types of histopathological alterations can be differentiated.