[S1 Clinical guideline"adenoids and adenoidectomy"]. / S1-Leitlinie "Adenoide Vegetationen/Rachenmandelhyperplasie".

On behalf of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery, a clinical guideline for adenoids and adenoidectomy was developed in 5 consensus meetings after taking into consideration the current literature. This guideline was released by the presidium on 13 April 2011. Anatomy, pathology and pathophysiology, symptoms, diagnosis, therapy, and course are presented.

[Guideline: Treatment of obstructive sleep apnea in adults]. / Leitlinie: Therapie der obstruktiven Schlafapnoe des Erwachsenen.

The current guideline discusses conservative and surgical therapy of obstructive sleep apnea (OSA) in adults from the perspective of the ear, nose and throat specialist. The revised guideline was commissioned by the German Society of Ear-Nose-Throat, Head-Neck Surgery (DG HNO KHC) and compiled by the DG HNO KHC's Working Group on Sleep Medicine. The guideline was based on a formal consensus procedure according to the guidelines set out by the German Association of Scientific Medical Societies (AWMF) in the form of a"S2e guideline". Research of the literature available on the subject up to and including December 2008 forms the basis for the recommendations. Evaluation of the publications found was made according to the recommendations of the Oxford Centre for Evidence-Based Medicine (OCEBM). This yielded a recommendation grade, whereby grade A represents highly evidence-based studies and grade D those with a low evidence base.

Endotracheal balloon dilatation and stent implantation in benign stenoses.

BACKGROUND: Tracheal reconstruction is the treatment of choice in nontumorous tracheal stenoses, but recurrences and concomitant medical conditions limit this approach. We investigated the outcome after balloon dilatation and silicone stent implantation. METHODS: Forty-two patients with inoperable tracheal stenoses underwent balloon dilatation and afterward silicone stent implantation. Patients were divided into two groups, in group A 24 patients received tracheal stents as a temporary treatment. In group B, definitive stenting was done in 18 patients with severe concomitant medical conditions that did not allow for stent removal. RESULTS: Immediate results were satisfactory in all patients. In group A, stents could be removed in 12 patients after a mean interval of 20 months. Restenting was not required during the following 18.9 months. Twelve patients are still waiting for stent removal after a mean follow-up of 20 months. In group B, mean follow-up is now 48.4 months. Complications included retained secretions, dislocation, and granuloma formation. CONCLUSIONS: Stenting after balloon dilatation is safe and effective in benign tracheal stenoses. After temporary use, stents can be removed when local and general conditions permit. In all other patients, stenting proved beneficial for 5 years as more definitive treatment.

[Virtual otoscopy--technique, indications and initial experiences with multislice spiral CT]. / Virtuelle Otoskopie--Technik, Indikationen und erste Erfahrungen mit dem Mehrschicht-Spiral-CT.

UNLABELLED: We report the standardized postprocessing of high-resolution CT data acquired by incremental CT and multi-slice CT in patients with suspected middle ear disorders to generate three-dimensional endoluminal views known as virtual otoscopy. MATERIALS AND METHODS: Subsequent to the definition of a postprocessing protocol, standardized endoluminal views of the middle ear were generated according to their otological relevance. The HRCT data sets of 26 ENT patients were transferred to a workstation and postprocessed to 52 virtual otoscopies. RESULTS: Generation of predefined endoluminal views from the HRCT data sets was possible in all patients. Virtual endoscopic views added meaningful information to the primary cross-sectional data in patients suffering from ossicular pathology, having contraindications for invasive tympanic endoscopy or being assessed for surgery of the tympanic cavity. Multi slice CT improved the visualization of subtle anatomic details such as the stapes suprastructure and reduced the scanning time. CONCLUSION: Virtual endoscopy allows for the non invasive endoluminal visualization of various tympanic lesions. Use of the multi-slice CT technique reduces the scanning time and improves image quality in terms of detail resolution.

Experimental in vitro and in vivo studies of epithelium formation on biomaterials seeded with isolated respiratory cells.

Extensive tracheal defects after intensive care medicine, trauma, or large resections in tumor surgery remain a major challenge in plastic and reconstructive surgery. Defects that cannot be satisfactorily treated by complicated and costly reconstructive techniques reveal a need for an alloplastic tracheal replacement. Recent experimental and clinical studies in the development of alloplastic tracheal prostheses proved that the lack of an epithelial lining on the luminal surfaces and inadequate biophysical properties and shapes of the prostheses were the main causes for failure of these prostheses. In this study a cell-seeding technique has been used. Adhesion, spreading, and differentiation of seeded mucosa cells on biomaterials in vitro were observed by scanning electron microscopy (SEM). Chemical properties and surface structure of the material influenced the differentiation process. Epithelium formation of incorporated tracheal prostheses was tested in animal experiments. Isolated respiratory cells were seeded into implanted tubular prostheses of porous polyurethane or expanded polytetrafluorethylene. Light microscopy and SEM showed the tendency of epithelium formation on the surface of the lumen. Vigorous cell layers, predominantly as multiple cell layers of squamous epithelium, were observed. Ciliated or mucus cells were not detected. It can be stated that the epithelium formation on incorporated porous implants is possible. Further studies of the stability and the differentiation process of the epithelium on such implants is needed before an introduction of tracheal replacements into the clinical practice can be considered.

Virtual endoscopy of the tympanic cavity based on high-resolution multislice computed tomographic data.

OBJECTIVE: This study was designed to assess the value of high-resolution multislice computed tomography (MSCT) data of the petrous bone for the virtual endoscopic visualization of the tympanic cavity. BACKGROUND: The recently introduced MSCT technology has improved spatial resolution in the z axis as well as scan speed in computed tomography. Three-dimensional rendering of high-resolution MSCT data of the petrous bone may be expected to provide endoluminal views of superior image quality, thus competing with transtympanic endoscopy (otoendoscopy). SETTING: This study was conducted at a university teaching hospital. MATERIALS AND METHODS: Cadaveric phantom studies in a MSCT scanner were performed to define a data acquisition protocol, combining adequate detail resolution with low tube current. Subsequently, the cadaveric phantom underwent otoendoscopy. The postprocessing parameters of the three-dimensional rendering protocol were chosen to produce views closely resembling the corresponding otoendoscopic images. High-resolution data from 18 patients with pathologic conditions of the middle ear, as suggested by clinical findings and assessment of cross-sectional data, were postprocessed using the volume rendering technique to generate standardized virtual endoscopic views. A total of 36 virtual endoscopic scans of the tympanic cavity were generated. RESULTS: With regard to intermediate and high-density structures, virtual endoscopic images, based on MSCT data, yielded endoluminal views closely resembling corresponding otoendoscopic views. Virtual endoscopy seems useful for imaging ossicular pathologic conditions such as dysplasia and chain disruption as well as for assessing patient status before and after otosurgery. CONCLUSION: MSCT data sets allow for generating virtual endoscopic views closely resembling otoendoscopic images. The technique is especially useful when ossicular pathologic changes are present as well as for preoperative and postoperative imaging of otologic procedures.

A new concept for reconstruction of atresias of larynx and trachea: lining of wound surfaces with autologous isolated respiratory epithelial cells.

A new method, first applied two years ago in our clinic, has proved to be reliable for achieving a rapid reepithelialisation of epithelial defects after scar removal inside the trachea. The defect is seeded with isolated respiratory epithelial cells harvested the day before from the ethmoid. Isolation of epithelial cells was achieved by keeping the mucosa in 0.25% trypsin buffer solution under room temperature for about 16 h. Afterwards, the epithelial layer was separated from the submucosa using small forceps and knife. Cells were then isolated by pipetting. For seeding the wound the surface was covered with silastic sheeting and the cell suspension then injected into the cleft between both of them. Cell distribution occurred by capillary attraction. The tracheal lumen was maintained by inserting a silastic stent for about three weeks. So far, 10 patients between 6 and 45 years have been treated in this way. In 4 patients the tracheal wall additionally had to be stabilized using rip cartilage. Only in one case above the tracheostoma, considerable scar formation occurred again requiring a second operation some months later. In 8 patients decannulation was meanwhile possible.

High-resolution petrous bone imaging using multi-slice computerized tomography.

Multi-slice computerized tomography (MSCT) is considered to provide superior image quality. We defined a data acquisition protocol for high-resolution (HR) temporal bone imaging using MSCT and assessed its impact on data acquisition and post-processing (PP). The data acquisition protocol was defined in cadaveric phantom studies performed by MSCT and subsequently applied to 38 patients referred for temporal bone assessment. The parameters image quality and diagnostic value of MSCT data were assessed for the cross-sectional source images as well as for 2-dimensional (2D) reformations and 3-dimensional (3D) reconstructions by 3 radiologists by comparison with incremental HR scans of 17 patients with suspected middle ear disorders. The data acquisition protocol yielded HR images with an excellent detail resolution and a comparable image quality of cross-sectional scans and related orthogonal reformations. MSCT achieved higher scores for image quality and diagnostic value (p < 0.001, t-test) than incremental HR CT with regard to both 2D and 3D reconstructions. MSCT improves the image quality of HR cross-sectional scans as well as that of 2D and 3D PP techniques in petrous bone imaging. The radiation exposure of the eye lenses is increased by MSCT as gantry angulation is not yet possible in the helical scan mode.

A post-processing protocol for three-dimensional visualization of the inner ear using the volume-rendering technique based on a standard magnetic resonance imaging protocol.

A superior diagnostic quality compared to other post-processing (PP) techniques for three-dimensional (3D) inner ear imaging has been attributed to volume rendering (VR). We defined and assessed a VR protocol for 3D visualization of the inner ear in a routine imaging setting. Following definition of a VR protocol by using lower threshold values, surface shading, perspective views and related parameters, standardized 3D views of the inner ear were generated and evaluated in 32 patients suffering from sensorineural or combined hearing loss. Comprehensive inner ear visualization was achieved in 28 patients by means of two 3D shaded-surface views. Incomplete data acquisition (1/32), motion and pulsation artefacts (2/32) and interposed fluid-retaining mastoid cells (1/32) were responsible for non-diagnostic image quality in 4/32 patients. In 5/32 patients modifications of the PP protocol involving the threshold value and depth-cueing parameters helped to establish diagnostic image quality. Mean post-processing time amounted to 5.8 min per site. 3D imaging with the VR technique is suitable for routine inner ear assessment if direct VR, predefined PP protocols and standardized labyrinthine views are used.

Use of cartilage grafts in the treatment of laryngotracheal stenoses and defects in children.

Stenosis of the laryngotracheal section is in most cases a sequel of intensive care treatment. Most of the children presenting with such stenoses need tracheostomy that in consequence impedes their physical, social and language development. Surgical treatment of stenosis and closure of tracheostomy as early as possible should be strived for. Reconstructive techniques using autogenous cartilage grafts have proved very effective. The aim of our study was to examine the influence of different methods on the structure and function of reconstructed airways. In 23 children between 2 and 16 years suffering from laryngotracheal stenosis we reconstructed the stenotic segments by insertion of autogenous cartilage grafts. Enlargement was achieved by cartilage implantation as a stent into the split cricoid plate in 16 children; in 3 cases we performed enlargement of the anterior wall and in 5 cases instable lateral walls of the trachea had to be reinforced. One child had to be treated with all three techniques at once. In another case the overstretched and soft posterior tracheal wall had to be stabilized. Enlargement of the cricoid plate has proved excellent in cases of a high degree of stenosis of the posterior commissure (Type III and IV of the Cotton classification). Subglottic stenoses Type II can be treated with anterior insertion of cartilage. The use of cartilage in surgical treatment of laryngotracheal stenosis in childhood leads to safe and sufficiently satisfactory results that do not hamper further development of either larynx or trachea.

[Elevatorium for fractures of the nasal bone and zygomatic arch]. / Elevatorium für Frakturen des Os nasale und des Arcus zygomaticus.

BACKGROUND: Unsuitable instruments are often used for the reduction of nasal fractures and fractures of the zygomatic arc. A new instrument for elevation and reduction of these common fractures is presented. METHOD: The special shape of the elevator, which is adapted to the anatomy of the nasal dome, is helpful in nasal surgery. The bayonet-shaped angle also allows elevation of compressed fragments of the zygomatic arc. RESULTS: This instrument was successfully used in the reduction of 107 bony fractures of the nose and 36 fractures of the zygomatic arc. CONCLUSION: From the clinical point of view the elevator can be recommended for ENT specialist working in a trauma setting.

[Nasal splint--space holder for after-care in endoscopic paranasal sinus operations]. / Nasensplint--Platzhalter für die Nachbehandlung nach endoskopischen NNH-Operationen.

BACKGROUND: Scars and synechiae in the middle meatus of the nose are dreaded late complications of endoscopic sinus surgery. The placement of a stent into the ethmoidal sinus for ventilation and drainage during and after the wound healing in the nose and the sinuses seems to be advantageous. METHOD: A nasal splint (Nasensplint, Primed, Halberstadt) made of silicone, consisting of an oval shaped plate and a lateral groove with an attached strap is presented. A part of the groove should be placed in the middle meatus of the nose. The plate also acts as a stent after septal surgery. Up to now the nasal splint was placed in 32 patients after endoscopic sinus surgery and were left in place for 5-14 days. RESULTS: All patients tolerated the stents. No side effects or complications were observed. In the postoperative controls (2-12 weeks) no synechiae were observed. CONCLUSION: The nasal splint presented here seems to be a useful solution for problems in postoperative wound healing after endoscopic sinus surgery. It can help to avoid fibrin bridges between corresponding wound surfaces.

[Middle ear adenoma. Long-term course of a rare neoplasm]. / Das Mittelohradenom. Langzeitverlauf einer seltenen Neoplasie.

Adenomas of the middle ear are rare benign glandular neoplasms arising from the middle ear mucosa. After previous operations 25 and 15 years before, a 67-year-old female complained about dizziness, tinnitus, and unilateral hearing loss on the left side. A tumor in the tympanum that was revealed by otoscopy could be removed completely. Histological examinations showed an adenoma of the middle ear with cholesteatoma. This was inconsistent with the histological result of the operation in 1983, which had described a hidradenoma. An exact analysis of the preparations confirmed that a middle ear adenoma had already been present in 1983. Hidradenoma is one of the most important differential diagnoses. The characteristic histological sign of middle ear adenomas in contrast to hidradenomas is the lack of myoepithelial cells. In addition, it is very difficult to differentiate middle ear adenoma and adenocarcinoma using histopathological and clinical methods. Therefore, thorough follow-up is mandatory for patients after surgical treatment of middle ear adenomas.

[Effect of the phytogenic secretolytic drug Gelomyrtol forte on mucociliary clearance of the maxillary sinus]. / Der Einfluss des pflanzlichen Sekretolytikums Gelomyrtol forte auf die mukoziliäre Clearance der Kieferhöhle.

BACKGROUND: To date, there has not been sufficient experimental evidence to demonstrate the pharmacological effect of secretolytic and mucolytic drugs. METHODS: Scintigraphic studies to detect the mucociliary clearance in the maxillary sinus before and after application of the secretolytic drug Gelomyrtol forte were performed on four healthy persons and one patient after sinus surgery. The most important parameter was the mucociliary transport velocity of the "region of interest-maxillary sinus" and the increase of radioactivity accumulated in a tampon placed in the middle meatus of the nose. Measurements were done with a gamma-camera, 99 m Technetium-sulphurcolloid was used as the radiopharmacentical. A dose of 1 MBq in 0.2 ml NaCl-solution was injected into the maxillary sinus. RESULTS: The results show a clear increase of mucociliary transport velocity in the maxillary sinus after intake of secretolytics in connection with an increase of radioactivity in the tampon. DISCUSSION: The results can be explained by the secretolytic and secretomotoric effects of the investigated drug. CONCLUSION: The study reveals that ethereal oils have secretolytic effects and also have a pharmacological effect on the mucociliary apparatus.

[Endotracheal silicon stents in therapy management of benign tracheal stenoses]. / Endotracheale Silikonstents im Therapiemanagement benigner Trachealstenosen. Ergebnisse nach 5-jähriger Anwendung.

BACKGROUND: Advances in endoscopic technique and the development of new materials have made stenting an interesting alternative to surgical treatment for extended tracheal stenoses. This 5 years' retrospective study describes long term results of silicon stents in patients with benign chronic tracheal stenoses. PATIENTS AND METHODS: 45 adult patients (mean age: 45 years) had endotracheal Dumon (Endoxane) stent placement as surgical therapy was not indicated. Fiberoptic controls were performed every 3-6 months. RESULTS: In 42 patients therapy proved successful with improved ventilation and high level of tolerance. Acut stent-removal was necessary in 2 patients because of edema of the vocal cords, in 1 patient because of stent independent paralysis of both recurrents nerves. Further complications included migration (16.6%), granuloma formation (33.3%) and airway obstruction due to heavy secretion (2.3%). CONCLUSIONS: Long term results have shown that this technique is associated with high efficiency and infrequent complications which are not life-threatening. Advantages consist in a minor-invasive technique with small expenditure of time.

[Protracted course of polychondritis as the etiology of progressive nose deformity, subglottic tracheal stenosis and inner ear hearing loss]. / Protrahiert verlaufende Polychondritis als Ursache für progrediente Nasendeformität, subglottische Trachealstenose und Innenohrschwerhörigkeit.

BACKGROUND: Relapsing polychondritis is a rare recurring inflammatory disorder with variable clinical course. Its etiopathogenesis is unknown, but autoimmune mechanisms are likely to be involved. PATIENT: We present a case report of a 42-year-old woman with polychondritis manifested in very slowly progressing destruction of the nasal cartilage, additional subglottic tracheal stenosis, and increasing cochlear dysfunction. RESULT: We describe and document by a series of photographs the very protracted course of the disease in this patient from early youth until now. Clinical signs and differential diagnosis in polychondritis are discussed. CONCLUSION: An early diagnosis in slowly progressing cases like this has to be established in order to permit adequate use of glucocorticoids and/or immunosuppressive drugs, to check the progress of the disease and prevent potentially lethal complications.

[Menière's disease. An analysis of clinical findings]. / Verlauf der Ménièreschen Erkrankung. Eine Analyse klinischer Befunde.

During a period of about 25 years 500 patients with Ménière's disease underwent treatment for their disease in the ENT clinic of the Charité Hospital in Berlin. In a long-term follow-up study of the course of the disease, 170 patients (80 female, 90 male) with a minimum duration of illness of 5 years could be registered. The detailed analysis based on differentiation of vertigo attacks, audiological and vestibular findings offered 3 different phases of the natural course of Méniére's disease: 1. Early phase: Vertigo attacks and fluctuating hearing loss mainly in the low-tone frequencies; 2. Chronic phase: Decrease of frequency and duration of attacks; 3. Late chronic phase: Hearing loss of nearly 50-60 dB and loss of vestibular excitability (caloric response, side difference ca. 50%). In consideration of neurological symptoms in the late chronic phase symptoms of Ménière's disease are changing into symptoms of vertebrobasilar insufficiency. The natural course of Ménière's disease and resulting therapeutical and diagnostical aspects require long-term therapeutic planning. An appropriate schedule is suggested.

[Mucociliary clearance of radically operated maxillary sinuses and effect of endoscopic ethmoid bone revision on the mucociliary system]. / Untersuchungen zur mukoziliären Clearance radikal voroperierter Kieferhöhlen und zum Einfluss der endoskopischen Siebbeinrevision auf deren Mukoziliarapparat.

Twenty-six maxillary sinuses (of 20 patients) were studied following Caldwell-Luc procedures. Surgery had been performed between 1 to 27 years previously. Follow-up studies included nasal endoscopy, coronal computed tomography and camera-sequence scintigraphy. Findings demonstrated that normalization of disturbed mucosal function was possible after surgery. Indications for revision endoscopic sinus surgery are discussed, as are the limitations of surgery.

[Classification of etiologic agents in fungal sinusitis by immunohistochemistry, histology and culture]. / Fungale SinusitidenErregerklassifizierung durch Immunhistologie, Histomorphologie und Kultur.

In the invasive forms of fungal sinusitis rapid identification of etiologic agent is of vital importance because of the different reaction of the fungi to various antifungal agents. In the non-invasive forms it is of interest for epidemiologic reasons and because of the potential transition to invasive and generalized mycoses in case of additional immunodeficiency. A diagnosis of fungal genus in histologic slides is desirable since up to 70% of the fungal cultures remain without result.In the present study 77 cases of fungal sinusitis were examined with the comercially available antibodies Anti-Aspergillus and Anti-Rhizomucor. The results of the histological examination and fungal cultures were added. The immunohistochemical examination permitted in 64 cases a classification as Aspergillus/Penicillium. Two cases caused by Zygomyzetes alone or in combination could be confirmed immunohistochemically. Four fungus balls showed no significant immunoreaction with both antibodies. If these where caused by other Hyphomycetes p.e. Pseudallescheria or if it where Aspergillus fungus balls that did not react because of extreme regressive change can not be decided.