[Advantages of piezoelectric technology in rhinoplasty]. / Vorteile der Piezo-Technologie in der Rhinoplastik.

BACKGROUND: Facial plastic and reconstructive surgery requires delicate, atraumatic handling of cartilage, bone and the surrounding soft tissue. Piezoelectric instrumentation (PEI) has previously been shown to be a precise and safe surgical instrument in rhinoplasty. It offers good preservation of surrounding soft tissue and high cutting precision and thus a good surgical applicability in rhinoplasty. OBJECTIVE: This article presents experiences using PEI for cartilage preparation and modelling for various indications in facial plastic surgery. The use of PEI in rhinoplasty, its safety and preciseness were evaluated and postoperative results are discussed with respect to facial swelling and bruising. MATERIAL AND METHODS: This retrospective study included 35 patients undergoing rhinoplasty and follow-up. Surgery was conducted by two expert surgeons in rhinoplasty in the department of otorhinolaryngology at the University Clinic of LMU Munich. Surgical performance of PEI in comparison with conventional instruments was evaluated by a customized questionnaire. The postoperative assessment of pain, facial swelling and bruising was documented. RESULTS: This article presents the different options for the use of PEI in rhinoplasty. In bone modelling procedures, such as hump removal, osteotomy and bony fixations, PEI was evaluated as being superior to conventional instruments. Intraoperative bleeding was reduced, which led to reduced facial swelling and/or bruising. Postoperative pain assessment showed no or only mild pain in two thirds of the patients. CONCLUSION: The results show that PEI enables a safe and very precise operation. Further development of surgical inserts will enable new surgical steps and facilitate the handling.

Use of a fibrinogen-thrombin sponge in rhinoplasty.

BACKGROUND: Although several methods have been described to address nasal dorsum augmentation and smoothing of irregularities in rhinoplasty, establishing the ideal method has proven controversial. OBJECTIVE: Here, we introduce a novel technique of cartilage grafting for nasal dorsum augmentation by wrapping cartilage in a fibrinogen- and thrombin-coated collagen patch called TachoSil®. MATERIAL AND METHODS: In a pilot study comprising ten cases, the use of the collagen patch was examined in various indications in rhinoplasty. Patients were clinically monitored for up to 8 months and photometric and sonographic documentation was performed pre- and postoperatively. RESULTS: In nine patients, the collagen patch was used for fixation of cartilage grafts in different indications: saddle nose deformities (n = 5), open roof (n = 1), nasal dorsum irregularities (n = 3). A diced cartilage graft enclosed by a bilayer of TachoSil® was applied in seven patients. Solid pieces of cartilage were either embedded in a bilayer of the collagen patch (n = 1) or covered by a monolayer (n = 1). Moreover, the collagen patch alone served as a soft tissue support in one patient with thin skin. Six patients were revision cases. All patients had uneventful healing without adverse events such as allergic reactions and infections. CONCLUSION: The collagen patch TachoSil® is eligible for various indications in rhinoplasty. It is a useful material predominantly for nasal dorsum augmentation by sandwiching diced or solid cartilage in the collagen patch, leading to better graft fixation and precise profile shaping. At the same time, TachoSil® helps with blood control. Follow-up studies will be performed to assess the material's long-term behavior.

[Otoplasty and quality of life]. / Ohranlegung und Lebensqualität.

The main aim of every aesthetic surgery is to offer patients a subjective benefit. Today, the construct "health-related quality of life" (HRQOL) is considered one of the most important parameters in the evaluation of treatment. Several recent studies using validated tools to measure HRQOL show that otoplasty leads to a significant and long-lasting increase in the HRQOL of children and adults suffering from protruding ears. However, irreversible auricular deformities after failed otoplasty can be more emotionally draining for the patient than the preoperative state. The respective risk is higher when using cartilage rasping or cutting techniques compared with pure suture techniques.

Diode laser versus radiofrequency treatment of the inferior turbinate - a randomized clinical trial.

BACKGROUND: Laser and radiofrequency induced volume reduction of the inferior turbinates are frequently used treatment modalities. Which of both is superior, however, is not clear to date due to a lack of controlled prospective studies. Here, we compare both methods regarding improvement of nasal breathing, complications, patient comfort and wound healing. METHODOLOGY: Prospective, randomized, single-blinded clinical trial with intra-individual design. After randomization, one side of the nose was treated with a 940nm diode laser and the other side with bipolar radiofrequency therapy. Pre- and postoperative evaluation was performed using visual analogue scales, nasal endoscopy and objective measurements of nasal patency. RESULTS: Of 27 enrolled patients, 26 completed the protocol. No severe complications were observed. Intraoperative discomfort was significantly more severe on the radiofrequency side. After three months, a significant reduction of nasal obstruction was observed for laser treatment and radiofrequency therapy with no significant difference between them. Objective parameters did not improve significantly. When asked which treatment modality they would chose again 50 % of the patients decided for radiofrequency treatment, 23 % for laser treatment, and 19 % for both. CONCLUSION: DLVR and RFVR are well-tolerated treatment modalities and both significantly reduce the degree of nasal obstruction in patients with hypertrophic inferior turbinates. There was no significant difference between both treatment modalities regarding efficiency.

[Prospective assessment of quality of life after auricular reconstruction with porous polyethylene]. / Prospektive Erfassung der Lebensqualität nach Ohrmuschelrekonstruktion mit porösem Polyethylen.

BACKGROUND: Microtia is associated with increased psychosocial morbidity. The literature contains three purely retrospective studies using validated tools. These studies show that auricular reconstruction leads to a significant improvement in health-related quality of life in affected children and adults. METHODS: In a prospective approach, the authors assessed 21 consecutive microtia patients (return rate 81 %; 7 children and 10 adults) before and after auricular reconstruction with porous polyethylene using the following validated questionnaires: Glasgow Health Status Inventory (GHSI), Short Form 36 Health Survey Questionnaire (SF-36), Childhood Experiences Questionnaire (CEQ) and Kidscreen-52. RESULTS: An improved health-related quality of life was detected with all applied instruments. CONCLUSION: A subjective benefit of auricular reconstruction with porous polyethylene can be shown using prospective, as well retrospective tools.

[Functional and aesthetic rehabilitation of microtia in children and adolescents]. / Funktionelle und ästhetische Rehabilitation der Mikrotie bei Kindern und Jugendlichen.

BACKGROUND: Microtia leads to a severe functional and aesthetic handicap. Traditionally, the auricle is often reconstructed with cartilage transplants, which is, however, associated with some partially substantial disadvantages. The authors have instead used implants of porous polyethylene for successful ear reconstruction for years, thus, avoiding some of these disadvantages. A significant benefit for the patient is achieved by simultaneous hearing rehabilitation by the implantation of active middle ear prostheses. METHODS: The authors present their surgical concept which allows functional and aesthetic rehabilitation of microtia in children and adolescents in a single operation. In the respective patient collective, audiometric measurements in quiet and noisy environments were conducted pre- and postoperatively, and health-related quality of life was determined using a validated questionnaire. RESULTS: All patients experienced a substantial hearing gain both in quiet and noisy environments. The evaluation of health-related quality of life showed a significant benefit from the intervention. CONCLUSION: Functional and aesthetic rehabilitation of microtia with active middle ear implants and ear reconstruction using porous polyethylene leads to good and reliable long-term results and can increase the health-related quality of life of affected children and adolescents. The main advantage of this concept is the possibility of a single procedure.

Lemierre syndrome: a case report.

INTRODUCTION: Lemierre syndrome, also known as postanginal sepsis, is caused by Fusobacterium necrophorum. This rare disease is usually characterized by thrombophlebitis of the jugular vein and septic embolism after a history of sore throat. OBJECTIVE: Here, we discuss a case of Lemierre syndrome in a 22-year-old man with thrombophlebitis of the facial vein and fusobacteria growth in the blood culture but no obvious focus of inflammation. METHOD: Case report. CONCLUSION: Severe facial infection with high fever and a general feeling of malaise after a history of sore throat should raise the diagnostic possibility of facial vein thrombophlebitis due to F. necrophorum infection.

[Correction of auricle deformities after failed otoplasty]. / Korrektur von Ohrmuscheldeformitäten infolge Ohranlegeplastik.

INTRODUCTION: Failed otoplasty can result in deformities which are more annoying than the preoperative state of prominent ears, especially if aggressive cutting or scoring techniques are used. This article describes how such deformities can be corrected successfully. METHODS: Ugly creases and edges can be corrected through readapting the cartilage edges followed by revision otoplasty using suture techniques. If cartilage defects are present, porous polyethylene implants can restore an aesthetic form of the auricle. RESULTS: The author has successfully treated 16 severe ear deformities after failed otoplasty in the last 3 years with the procedures described. CONCLUSIONS: The author recommends reconstructing the cartilaginous skeleton and redoing otoplasty with suture techniques rather than merely camouflaging creases with fascia or preserved materials. Porous polyethylene implants can successfully be used instead of autogenous cartilage to reconstruct a missing ear cartilage skeleton.

Intraductally applied contrast-enhanced ultrasound (IA-CEUS) for evaluating obstructive disease and secretory dysfunction of the salivary glands.

Obstructive diseases of the salivary glands are a common problem, usually based on sialolithiasis, duct stenosis, foreign bodies or other more rare causes. Secretory dysfunction, often associated with Sjögren syndrome or post radiation treatment, is also a frequent problem. Several diagnostic tools exist to classify the disease; however conventional radiological imaging or ultrasound does not provide a diagnosis in 5-10% of all cases. Intraductally applied contrast-enhanced ultrasound (IA-CEUS) improves the visualization of obstructive diseases of the salivary glands. IA-CEUS is a promising tool for assessing the ductal system and to diagnose and characterize abnormalities. This study describes the assessment of IA-CEUS in diagnosing different obstructive and chronic inflammatory conditions of the salivary glands.

Evaluation of an image-guided navigation system in the training of functional endoscopic sinus surgeons. A prospective, randomised clinical study.

INTRODUCTION: Many sinus surgeons report improved spatial orientation after using a navigation system. This study investigates the surgical, ergonomic and economic aspects of using a navigation system in training and teaching. MATERIALS AND METHODS: Eight rhino-surgeons in training and 32 patients with bilateral diseases of the paranasal sinus system were included. After randomisation, one patient`s side was operated on with a navigation system while the other side was operated on without navigation. It was monitored how often the surgeon used the navigation pointer and then changed the procedures. A standardised and validated interview recorded the cognitive load when using the navigation system and the application efficiency. RESULTS: The operations lasted on average 16 minutes longer with the navigation. Five paranasal sinuses could not be found in the control group without navigation. In only 10-13% of cases did the surgical procedure change after the use of the pointer. Most of the surgeons admitted that particular steps of the operation were more reliable and safer to carry out with the navigation system. The general trust in the system rose in proportion to intraoperative accuracy and repeated use. CONCLUSION: Overall, there was an overwhelming level of trust in the navigation system. Trainee sinus surgeons seeing their more experienced colleagues using a navigation device tend to overestimate the possibilities of the system and to underestimate the risks. The assistance system was used particularly effectively in the group of slightly more experienced surgeons. In this group, the additional expenditure of time was less and the navigation substantially contributed to reinforcing the anatomical sense of direction.

[Orbital and intracranial complications of acute sinusitis. Diagnostics and therapy in children and adolescents]. / Orbitale und intrakranielle Komplikationen akuter Sinusitiden. Diagnostik und Therapie bei Kindern und Jugendlichen.

Orbital and intracranial complications of acute sinusitis occur more frequently in the pediatric population compared to adults due to anatomic differences. Since the introduction of antibiotics the frequency of such complications has been dramatically reduced. Nevertheless, even in the era of modern antibiotics these complications continue to occur and it is therefore of utmost importance not only to know about these complications but also to include them in the differential diagnosis. Appropriate diagnosis mainly based on CT scanning or magnetic resonance tomography is the basis for a rapid and sufficient and if necessary interdisciplinary treatment. In this CME article the diagnostic and therapeutic interventions in four young patients suffering from orbital or intracranial complications due to acute sinusitis are described and discussed in the context of the current literature and a clinical algorithm is introduced.

[Sonographic analyses of obstructive diseases of the salivary gland using intraductal applications of contrast agent]. / Sonografische Analyse von obstruktiven Speicheldrüsenerkrankungen mittels intraduktaler Kontrastmittelapplikation.

Obstructive diseases of the salivary glands are a common problem of the salivary glands; often based on Sialolithiasis, duct stenosis, or other rarer reasons. There exist several diagnostic features to classify the disease; however, ultrasound or conventional radiological imaging does not provide a diagnosis in 5-10% of all cases. The intraductal applied contrast-enhanced ultrasound (IA-CEUS) improves the visualization of obstructive diseases of the salivary glands; simultaneously an evaluation of the parenchyma of the glands is possible. We think IA-CEUS is a promising tool, which improved the diagnostic assessment capabilities of ultrasound and results in a better treatment for patients with obstructive salivary gland diseases.

[Symptoms and treatment of choanal atresia--stenting remains controversial]. / Symptome und Therapie der Choanalatresie--Stents weiterhin umstritten.

Congenital choanal atresia is a rare malformation of the upper airways occurring sole or within the scope of syndromes. The controversy regarding standardized surgical approach and optimal technique preventing re-stenosis as well as the proceeding in case of a unilateral malformation persists. To address these issues, a retrospective analysis of patients presenting with choanal atresia in our department within the last 10 years was performed. 15 infants aged 3 days to 13 years (mean 42 months) who presented with unilateral (10 cases) and bilateral (5 cases) choanal atresia underwent surgical repair. 4 patients failed previous surgeries. All interventions were performed in transnasal endoscopic technique. 7 patients were intraoperatively stented for 6 weeks, 4 patients for 1 week. In 73% (11 out of 15 children) further congenital anomalies were identified. In 7 cases a re-stenosis requiring treatment occurred, predominantly in long-term stented patients. No intra- or postoperative hemorrhages or infections occurred. To provide an adequate work-up of affected patient including a screening for further congenital anomalies, a multidisciplinary approach is required. Endonasal endoscopic approach represents a safe technique for surgical repair of choanal atresia. The indication for surgical repair in case of a unilateral atresia is based on the severity of clinical symptoms. The use of stents, especially of long term, remains controversial and needs further evaluation.

Management of orbital complications due to rhinosinusitis.

Emergencies in sinusitis are in 60-75% orbital complications defined by blepharedema (stage I), periostitis (stage II), subperiostal abscesses (SPA) (stage III) and orbital cellulites (stage IV). Ophthalmic complications such as diplopia, exophthalmia and reduced visual acuity are seen in stages III and IV. There is a consensus for primary conservative treatment in stage I or II and until recently for surgery in stages III and IV. The discussion concerns the decision for surgery versus conservative therapy in stage III in children. Another question is the definitive outcome of ophthalmic symptoms. The charts of 127 patients with orbital complications of sinusitis from 1995 until 2003 were analyzed. A follow-up questionnaire was sent to all asking for general quality of life, ophthalmic symptoms, and symptoms of sinusitis, further surgery or other treatments. The ratio of male to female was 2.3:1; 32 of the patients (25.2%) were ≤ 16 years and 37% had chronic rhinosinusitis. Of the adult patients, 37.9% had blepharedema, 45.3% periostitis, 4.2% SPA and 12.6% orbital cellulitis (children: 31.3, 40.6, 12.5 and 15.6%). Children with orbital cellulites were significantly (P < 0.01) older than those with SPA. Motility disorders, e.g., diplopia, were seen in 11%, exophthalmia in 12% and reduced visual acuity in 5.5%. As much as 51.2% were treated conservatively. Intervention was endoscopic sinus surgery in 81% and a combined intervention in 19%. After a mean of 40.5 months, 6 of 55 patients who had returned the questionnaire still had ophthalmic symptoms. Treatment of stages I and II are conservative, but if it fails surgery is required within 24-28 h. There is a trend for a more conservative therapy in children with stage III. However, we plead for a flexible approach to therapy in stage III and for primary surgery in patients with recurrent chronic sinusitis.

[Rhinoplasty: open or closed technique?]. / Rhinoplastik: Offene oder geschlossene Technik?

The present article gives a short historical overview of rhinoplasty. Frequency as well as advantages and disadvantages of the open and closed techniques are discussed. The choice of the surgical access depends on the current flow and the surgeon's experience. Regional differences do exist. It is essential to have sufficient knowledge of both techniques, in order that the surgeon can choose the appropriate technique according to the wishes of the patient. Primarily, an endonasal approach should be aimed for.

[Reconstructive nasal surgery--the problem of the internal lining]. / Rekonstruktive Nasenchirurgie--das Problem der Innenauskleidung.

Careful internal defect coverage is important for a well vascularised internal base for the transplant in reconstructive nasal surgery. Secondary healing of intranasal wounds often results in nostril contracture and scar stenosis. The choice of methods for surgical coverage depends on the location of the defect and the condition of surrounding elements. For example, the double-stemmed "pot handle" flap is suitable for small defects of the internal lining of the nasal lobule. The septal mucosa flap can be used for larger and more complex defects of the internal nasal lining. Using composite skin and cartilage grafts from the ear, three-layered nasal defects can be treated in a variety of ways. The turn-in flap is a tilt flap and is very versatile for the treatment of inner defects of the lower nasal half.

A simple energy filter for low energy electron microscopy/photoelectron emission microscopy instruments.

Addition of an electron energy filter to low energy electron microscopy (LEEM) and photoelectron emission microscopy (PEEM) instruments greatly improves their analytical capabilities. However, such filters tend to be quite complex, both electron optically and mechanically. Here we describe a simple energy filter for the existing IBM LEEM/PEEM instrument, which is realized by adding a single scanning aperture slit to the objective transfer optics, without any further modifications to the microscope. This energy filter displays a very high energy resolution ΔE/E = 2 × 10(-5), and a non-isochromaticity of ∼0.5 eV/10 µm. The setup is capable of recording selected area electron energy spectra and angular distributions at 0.15 eV energy resolution, as well as energy filtered images with a 1.5 eV energy pass band at an estimated spatial resolution of ∼10 nm. We demonstrate the use of this energy filter in imaging and spectroscopy of surfaces using a laboratory-based He I (21.2 eV) light source, as well as imaging of Ag nanowires on Si(001) using the 4 eV energy loss Ag plasmon.