Mapping of language and motor function during awake neurosurgery with intraoperative optical imaging.

Intraoperative optical imaging (IOI) is a marker-free, contactless, and noninvasive imaging technique that is able to visualize metabolic changes of the brain surface following neuronal activation. Although it has been used in the past mainly for the identification of functional brain areas under general anesthesia, the authors investigated the potential of the method during awake surgery. Measurements were performed in 10 patients who underwent resection of lesions within or adjacent to cortical language or motor sites. IOI was applied in 3 different scenarios: identification of motor areas by using finger-tapping tasks, identification of language areas by using speech tasks (overt and silent speech), and a novel approach-the application of IOI as a feedback tool during direct electrical stimulation (DES) mapping of language. The functional maps, which were calculated from the IOI data (activity maps), were qualitatively compared with the functional MRI (fMRI) and the electrophysiological testing results during the surgical procedure to assess their potential benefit for surgical decision-making.The results reveal that the intraoperative identification of motor sites with IOI in good agreement with the preoperatively acquired fMRI and the intraoperative electrophysiological measurements is possible. Because IOI provides spatially highly resolved maps with minimal additional hardware effort, the application of the technique for motor site identification seems to be beneficial in awake procedures. The identification of language processing sites with IOI was also possible, but in the majority of cases significant differences between fMRI, IOI, and DES were visible, and therefore according to the authors' findings the IOI results are too unspecific to be useful for intraoperative decision-making with respect to exact language localization. For this purpose, DES mapping will remain the method of choice.Nevertheless, the IOI technique can provide additional value during the language mapping procedure with DES. Using a simple difference imaging approach, the authors were able to visualize and calculate the spatial extent of activation for each stimulation. This might enable surgeons in the future to optimize the mapping process. Additionally, differences between tumor and nontumor stimulation sites were observed with respect to the spatial extent of the changes in cortical optical properties. These findings provide further evidence that the method allows the assessment of the functional state of neurovascular coupling and is therefore suited for the delineation of pathologically altered tissue.

Hoarseness ­ causes and treatments. / Heiserkeit Ursachen und Therapie.

Due to a hoarseness or dysphonia about 1 % of patients consult a doctor. The causes of hoarseness are very diverse and can range from a harmless laryngitis to vocal cord tumors. In addition to acute and chronic laryngitis (42 % and 10 %), functional dysphonia (30 %), benign (15 %) and malignant tumors (3 %), vocal cord paresis (5 %), the physiological aging voice (2 %) and psychogenic factors (2 %) can cause hoarseness. The manifestation of internal diseases is very rare. Treatment options depending on the cause are drugs, voice therapy or surgery. The present article gives an overview of possible causes of hoarseness, diagnosis and treatment options. Hoarseness lasting more than three weeks should always be taken seriously and be examined laryngoscopically.

[Differential diagnostic and therapeutic aspects of nasal obstruction]. / Differenzialdiagnostische und therapeutische Aspekte.

A nasal obstruction can have various causes. This publication describes various diseases of the nose and paranasal sinuses which cause nasal obstruction or which are associated with the symptom of nasal obstruction. The diagnosis and treatment of the diseases is discussed. Anatomical, physiological aspects and the general diagnosis of diseases of the nose and sinuses are also considered.

Epistaxis: some aspects of laterality in 326 patients.

Lateralization of primary epistaxis was prospectively studied in 326 patients at Radebeul Elblandklinikum. The male-female-ratio was 1.3:1. A slight dominance of the right side (45% right vs. 39% left) was found in all patients. Further analyzed were the relationship to the localization of bleeding (anterior or posterior), the age and possible causes or risk factors. Nose bleeding from the posterior nasal portion appears to be statistically significantly higher than on both sides of anterior epistaxis. No statistically significant age dependence of laterality of epistaxis was observed in the age groups which we selected. However, nosebleed appears more frequently in women under the age of 50 years in both nostrils. With identified risk factors, idiopathic epistaxis occurs more frequently on the right side than does nosebleed. Mechanical trauma (intranasal sprays or nose picking) is a possible factor explaining the dominance of epistaxis on the right side, especially in idiopathic cases.

Vestibular neuritis: is there any evidence of an asymmetric distribution?

Statistics in the literature showed that neuro-otological diseases (i.e. sudden hearing loss or tinnitus) occur predominantly in the left ear. In a seven-study meta-analysis of patients suffering from vestibular neuritis, Reiß found no clear dominance of one side (50.8% on the right side, 48.4% on the left side and 0.8% on both sides). The purpose of this study is to investigate the laterality of vestibular neuritis in a distinct population of patients. Lateralization of vestibular neuritis was studied in 160 patients treated at Elblandklinikum Radebeul from January 2004 to December 2009. There was a statistically non-significant dominance of the right side in the total sample, specifically in female patients (57% right vs. 40% left), but not in male patients. The study confirms the results of the meta-analysis: that there is no relevant side dominance in patients suffering from vestibular neuritis. In addition to the caloric test, the head impulse test was performed in 157 patients. In 92% of these patients, the disturbance of vestibular function could be confirmed with the head impulse test. This test is altogether a clinically useful instrument especially for follow-up, but also for diagnosis.

[Pharmacotherapy of acute and chronic tinnitus]. / Die medikamentöse Therapie des akuten und chronischen Tinnitus.

The aetiology of acute tinnitus is mostly idiopathic like sudden sensorineural hearing loss or caused by noise and rarely infectious or vascular. Therefore there is currently no causal and effective drug therapy available. Although there is a low level of evidence, treatment with glucocorticoids and initially plasma expanding infusions (HES) is recommended for acute tinnitus if there is no spontaneous remission. Intratympanic glucocorticoid therapy can be used as an alternative if there is severe hearing loss together with tinnitus. In chronic tinnitus there is really no indication for pharmacotherapy. Sometimes

[Conservative therapy of chronic sinusitis]. / Therapie der chronischen Rhinosinusitis.

The chronic rhinosinusitis is defined as chronic inflammation of the nose and nasal sinuses, with or without nasal polyps. Patients suffering from chronic rhinosinusitis report about nasal obstruction and secretion, olfactory impairment, head and facial pain. These symptoms cause also considerable impact on quality of life. Therefore, an adequate rhinological diagnostics as well as therapies are essential. This paper reviews the pharmacologic and non-pharmacologic therapy of chronic rhinosinusitis. First choice of therapy should be topical glucocorticoids. The application of glucocorticoids causes anti-inflammatory and certain curative effects. Hypertonic salt solutions improve nasal symptoms. Long-term therapy with oral macrolides might improve median to severe symptoms of chronic rhinosinusitis without nasal polyps. An additional therapy with antihistamines is possible in patients with an allergy. Adaptive desensitization in patients suffering from analgesic-intolerance associating among other with nasal polyps is currently the single causal therapy. Therefore, frequency of endonasal revision surgery is reduced after desensitization.

Vestibular Schwannoma Surgery: Outcome and Complications in Lateral Decubitus Position versus Semi-sitting Position-A Personal Learning Curve in a Series of 544 Cases over 3 Decades.

OBJECTIVE: To retrospectively evaluate influence of intraoperative positioning (semisitting vs. lateral decubitus) and surgeon's learning curve with regard to functional outcome of patients with vestibular schwannoma. METHODS: This study included 544 patients (median age 57 years) and spanned 3 decades: 1991-1999 (n = 103), 2000-2009 (n = 210), and 2010-2019 (n = 231). Surgery was performed in the lateral decubitus position in 318 patients and the semisitting position in 163 patients. Large T3 and T4 tumors were present in 77% of patients. RESULTS: Complete tumor removal was achieved in 94.3% of patients. A significant reduction in surgery duration and blood loss was observed over 3 decades for T3 (from 325 to 261 minutes, P < 0.001) and T4 (from 440 to 330 minutes, P < 0.001), but not for T1 and T2, tumors. The semisitting position diminished surgical time in T3 and T4 tumors by 1 more hour (P < 0.001). Over 3 decades, facial nerve outcome improved significantly from 59.8% House-Brackmann grade 1-2 in the first decade to 81.7% in the last decade (P < 0.001). Furthermore, hearing was preserved in 45.3%: 23.3% of patients in the first decade and 50.5% in the last decade (P = 0.03). However, neither facial nerve outcome nor hearing preservation significantly differed in patients operated on in the lateral decubitus versus the semisitting position. The most common complication was cerebrospinal fluid leak (6.1%) followed by hemorrhage (3.5%) and pulmonary embolism (2.2%). CONCLUSIONS: Follow-up over 3 decades illustrates a learning curve with significantly improved results. While the semisitting position accelerates the procedure and is associated with reduced blood loss, it does not significantly influence functional outcome.

[Epistaxis: diagnosis and therapy]. / Epistaxis: Ursachen, Diagnostik und Therapie.

Epistaxis or nosebleed is one of the most frequent emergencies in otorhinolaryngology. It is clearly an important condition--not only to the ear-nose-throat (ENT)-specialist but also to any general practitioner. This review looks at the aetiology, associated clinical considerations and evolution of its management. Intractable epistaxis requires a broad armamentarium of different diagnostic and therapeutic options.

[Suppurative chronic otitis media: etiology, diagnosis and therapy]. / Die chronische eitrige Otitis: Ursachen, Diagnostik und Therapie.

The chronic otitis media is defined as a permanent perforation of the drum membrane, which does not close by itself, and an inflammatory reaction in the mucosa (mucositis) of the middle ear. Two main forms of the chronic otitis media are distinct: the suppurative otitis media and the cholesteatoma. The suppurative otitis media is often accompanied by secretion into the external ear canal (otorrhoe), but "dry ears" are also common. Other frequent, but not obligatory symptoms are hearing impairment, tinnitus, and aural pain or pressure. Although genetically determined microbial and immunological factors, as well as Eustachian tube characteristics, are supposed to be involved in the pathogenesis of chronic suppurative otitis media, many aspects of the pathogenesis still need to be clarified. Ear microscopy will show the perforation in the drum membrane. Further diagnostic tools are audiometry, vestibular testing, radiological examination (high-resolution computed tomography) and microbiological investigation. The curative treatment for chronic suppurative otitis media is surgery (tympanoplasty, i.e. closure of the perforation in the drum membrane and also--if necessary--the reconstruction of the ossicular chain), not conservative antimicrobial therapy.

Earedness and auricles.

No strong relationship was observed between earedness and the asymmetry of prominent auricles, suggesting no important function of the auricles in ear preference.

[Analgesic intolerance: pathogenesis, diagnosis and treatment]. / Analgetikaintoleranz. Ursachen, Diagnostik und Therapie.

Analgesic intolerance brings on cutaneous, respiratory and/or gastrointestinal reactions. This review provides an overview of sensitivity to nonsteroidal anti-inflammatory-drugs (NSAR) and its management. The full clinical picture of analgetic intolerance--the association of bronchial asthma (with severe acute attacks), sensitivity to NSAR and nasal polyps--is commonly summarized as the "Samter triad". The symptoms include chronic rhinosinusitis with nasal polyps, asthma bronchiale, gastrointestinal ulcers, angioedema, and urticaria. The prevalence of analgetic intolerance in the general population ranges from 0.6 to 2.5%. Clinical reactions after ingestion of NSAR are often obvious in the further progress of disease. In order to initiate early therapy the diagnosis of analgesic intolerance should occur before the complete picture of analgesic intolerance is obvious. Carefully controlled challenge tests with acetyl salicylic acid or other NSAR are performed as the diagnostic but not potential undamaged tool of choice. Adaptive desensitization (Aspirin desensitization therapy) is currently the single causal therapy. Severe asthma and reactions after ingestion of NSAR are avoided. Frequency of endonasal revision surgery is reduced after desensitization.

[Presbyacusis: pathogenesis and treatment]. / Schwerhörigkeit im Alter. Ursachen und Behandlung.

Although many adults retain good hearing as they age, hearing loss associated with ageing is common among elderly persons. There are a number of pathophysiological processes underlying age-related changes to functional components. Presbyacusis is especially caused by cochlear degeneration, most pronounced in the basal cochlear coil. Factors include physiological ageing processes as well as endogenous or exogenous causes. The common form of hardness of hearing seen in old age is not due to physiological age-related changes, but rather to a complex sensorineural pattern of injury. In the industrial countries, two main exogenous causes are exposure to loud noise and obesity. Pathomechanisms contributing to presbyacusis are hypoxia/ischemia, reactive species formation and oxidative stress, apoptotic and necrotic death of hair cells and spiral ganglion cells as well as inherited and acquired mutations in the mitochondrial DNA. Important for the successful treatment of presbyacusis is a timely fitting of hearing aids on both ears to improve communication, provide the auditory system with acoustic information, and potential prevention of social isolation. At present, several therapeutic interventions are under discussion. The application of antioxidants or caloric restriction is considered to prevent or reduce oxidative stress-induced damage. A further approach may be the overexpression or modulation of the superoxide dismutase 2 (SOD2) within the cochlea. Hair cell regeneration could also be a possible treatment of presbyacusis in the future.

[Piercing--medical problems from otorhinolaryngological point of view]. / Piercing--medizinische Probleme aus HNO-ärztlicher Sicht.

Piercing is defined as puncturing an organ in order to place a jewel in the perforated site. There is hardly any external organ in the human body that has escaped piercing. The origin of piercing traces back to the dawn of human history. Piercing is performed for decorative or symbolic purposes. Many different medical specialists are confronted with the increasingly popular practice of body piercing in their daily practice. Until recently body piercing was mainly confined to the ears and/or nose. In the last few years there has been a significant increase in the prevalence of body piercing. There are a lot of side effects, among them especially infections. The most important bacteria cultivated from such patients are Staphylococcus aureus and group A streptococci and Pseudomonas aeruginosa. Viruses which can be transmitted by piercing are especially hepatitis B virus and hepatitis C virus. Besides local complications also systemic infections (sepsis, endocarditis) occur. The main aspects of diagnostics, therapy and prevention are discussed.

[Sialorrhea--causes and treatment options]. / Sialorrhö. Ursachen und Behandlungsmöglichkeiten.

Sialorrhea (drooling) is the involuntary spillage of saliva from the mouth. Drooling of saliva appears to be the consequence of a dysfunction in the coordination of the swallowing mechanism, resulting in excess pooling of saliva in the anterior portion of the oral cavity and the unintentional loss of saliva from the mouth. There are specific and symptomatic approaches to manage this condition. Treatment options range from conservative (i.e., observation, postural changes, biofeedback, motoric therapy of the mouth, acupuncture) to more aggressive measures such as medication, radiation, and surgical therapy.

Loss of trigeminal sensitivity reduces olfactory function.

The trigeminal and olfactory nerves share overlapping innervation areas in the nasal cavity and seem to work in an interactive way. Loss of olfactory function leads to a decreased trigeminal sensitivity, as shown in anosmic subjects. To report the impact of disturbed trigeminal sensitivity on the olfactory function, we present a patient with unilateral loss of trigeminal function resulting from a meningeoma. Thresholds to a selective olfactory stimulus were elevated by a factor of 64 on the affected side. Recordings of event-related potentials in response to olfactory stimuli showed a significantly reduced response on the affected side. This report indicates that loss of trigeminal function may affect the sense of smell.

[Dry mouth]. / Mundtrockenheit. Ursachen und Therapiemöglichkeiten.

Dryness of the mouth (xerostomia) is a serious problem for the affected patients, in particular if it is caused by a reduced salivation. Triggering factors are, e.g., drugs (antihypertensives, neuroleptics), CNS disorders, chronic obstruction of nasal breathing, irradiation therapy of head-neck tumors, Sjögren's syndrome, sarcoidosis, or diabetes mellitus. Patients with xerostomia should be diagnosed and treated on an interdisciplinary basis. Several causal and symptomatic therapeutic options are available, including local stimulation of salivation. In addition, prevention is to be emphasized. In most patients symptomatic improvement and thus an improved quality of life can be achieved.

[Sleep disturbances--aspects of obstructive and sleep-related breathing disorders]. / Schlafstörungen--Aspekte obstruktiver schlafbezogener Atemstörungen.

Obstructive sleep apnea (OSA) is a wide spread affliction in industrialised countries. OSA has to be distinguished from simple snoring which is socially annoying but physically harmless, since it does not harm the physical health. Patients with OSA complain about disruptive snoring, daytime sleepiness, and loss of intellectual power. OSA is associated with increased mortality. It is possible to distinguish between complete respiratory pauses or apnoea and periods of too shallow breathing or hypopnoea. History taking, clinical examination, recording of daytime sleepiness, and cardio-respiratory sleep studies are necessary to make a proper diagnosis. OSA should primarily be treated, not so the simple snoring. In sleep apneics the treatment focuses on the removal of the sleep-related breathing disturbances and their health-related consequences. Therefore adjuvants or minimally invasive surgical techniques are favoured. Gold standard treatment of OSA is nasally applied continuous positive airway pressure (nCPAP). Alternative treatment modalities are also used. As conservative approaches oral appliances and conditioning (to avoid supine sleeping position) show promising results. Surgical treatment complies with the severity of the disease and with the anatomical findings. A variety of surgical approaches to the soft palate, the base of tongue, the tonsils, and the upper and lower jaws have been described.