[Traumatology-an interdisciplinary task: exclusively for educational purposes?] / Traumatologie ­ eine interdisziplinäre Aufgabe: nur in der Lehre?

BACKGROUND: Traumatology of the head and neck region is not only a part of otorhinolaryngology, but also has a large overlap with neighboring disciplines of the head and neck region. In Freiburg, an interdisciplinary lecture on "ENT emergencies" was implemented in the 21/22 winter semester. The aim was to provide an even more realistic view on interdisciplinary patient care and to make evident the areas of intersection of four of the major head disciplines (otorhinolaryngology, neurosurgery, ophthalmology, and maxillofacial surgery). MATERIALS AND METHODS: A new, special lecture in otorhinolaryngology was implemented as part of the regular online lecture series accompanying the semester. With reference to the clinical care of ENT emergencies, possible overlaps with neighboring disciplines were identified and explained by the discipline representatives or discussed in front of and with the auditorium. At the end of the semester, all participating students (n = 173) were invited to evaluate the seminar using the survey tool "EvaSys" (EvaSys GmbH, Lüneburg, Germany). In total, 78 students participated in the evaluation process. RESULTS: The new lecture concept was very well accepted and immediately ranked top among the interdisciplinary lecture titles within the ENT lecture series. The clear communication of the term "interdisciplinarity" in the sense of a complementary clinical cooperation was also very successful and was appreciated accordingly by students during the evaluation process. CONCLUSION: Pragmatic presentation of ideal clinical patient care using an interdisciplinary approach is possible within the regular ENT lecture series. This realistic portrayal, beyond any technical and/or professional differences, is of great interest to students and is considered clinically relevant. Thus, interdisciplinary lectures provide a valuable tool to teach the fundamental values of clinical interdisciplinary management for the best possible patient care.

[Objective and subjective assessment of a structured approach to computed tomography scans of the paranasal sinuses]. / Objektive und subjektive Bewertung eines strukturierten Vorgehens zur Beurteilung von Computertomographien der Nasennebenhöhlen.

BACKGROUND: Sound knowledge of individual anatomy is essential in sinus surgery to prevent potentially serious complications. For the paranasal sinuses, computed tomography (CT) is the imaging technique of choice to preoperatively analyze individual anatomy and the extent of disease. OBJECTIVE: The purpose of this study was to evaluate the usefulness of a CT checklist to identify relevant anatomic variants in CTs of the paranasal sinuses. MATERIALS AND METHODS: Junior and senior otolaryngology residents were asked to assess sinus CT scans for anatomic variants before and after implementation of the CLOSE mnemonic (cribriform plate, lamina papyracea, Onodi cell, sphenoid sinus pneumatization, and [anterior] ethmoidal artery). The rate of correctly identified variants was calculated. A questionnaire was distributed for subjective evaluation of the usefulness of the checklist. RESULTS: Six junior and six senior residents were included in the study. The rate of correctly identified anatomic variations significantly improved from 23.1 to 50.9% and 24 to 39.8%, respectively, after implementation of the CLOSE mnemonic. The subjective evaluation of the CLOSE criteria showed very positive results. CONCLUSION: The structured approach to sinus CT scans using CT criteria can improve identification of critical anatomic variants in CT scans of the paranasal sinuses and is rated highly positively by residents in training.

[Social reimbursement-the Spanish-German ENT Society's (SDGHNO) Latin America project]. / Soziale Rückvergütung ­ das Projekt "Lateinamerika" der Spanisch-Deutschen HNO-Gesellschaft (SDGHNO).

Nowadays, social projects are usually oriented in such a way that after a given period of time, they can either support themselves independently or even allow a pecuniary reimbursement. In the latter case, experts speak of a profit-oriented reimbursement. On the other hand, there is so-called social reimbursement, which in contrast to the abovementioned form is not profit oriented, but, for example, considers its task fulfilled by the fact of successful knowledge transfer. The Spanish-German Society for ENT Medicine and Head and Neck Surgery (SDGHNO) launched the Latin America project in 2001 under the patronage of the then President Prof. Dr. Wolfgang Draf (Fulda). The goal of the SDGHNO was and is to create a professional as well as cultural platform for Spanish- and German-speaking ENT doctors. This platform can and should be used for professional purposes, e.g., for knowledge transfer. Since the beginning of its existence, the Latin America project has thus brought numerous scientific events into being and created specific contacts which have lasted until today or have even been continued and further developed. Particularly successful examples are Chile, Colombia, and Peru. This is a vivid example of social reimbursement, because the participating German-speaking members/speakers carried out their tasks on an entirely voluntary basis. Thus, the SDGHNO did not bear any travel, catering, or accommodation costs. The activities of the SDGHNO within the framework of the Latin America project are explained.

Aesthetic and functional outcomes in patients with a nasal prosthesis.

The aim was to evaluate the aesthetic and functional outcomes in patients with a nasal prosthesis after radical tumour resection. A questionnaire with 15 domains was created to evaluate the satisfaction of patients with their nasal prosthesis. Correlations with the results of the University of Washington Quality of Life (UWQOL) questionnaire, which was also completed by the patients, were analyzed. Forty-three patients with a partial or total nasal prosthesis completed the questionnaire. Twenty-seven patients were male and 16 were female; their median age was 62 years. The median follow-up time after tumour resection was 33 months. The best result was obtained for overall function (85.5) and the worst result for nasal crusts (58.5). The average daily duration of prosthesis use was 17.4h. There were sex-dependent and age-dependent differences in the domain 'self-confidence', age-dependent differences in the domain 'stability during sporting activities', and differences in the domain 'nose bleed' depending on the time since tumour resection. All patients would recommend this rehabilitation after rhinectomy. 'Satisfaction with function' had the most influence on UWQOL domains. The nasal prosthesis is a well-accepted rehabilitation after rhinectomy. The results for appearance are comparable to those obtained for nasal reconstruction, and high scores were found for the functional domains.

Clinical investigation of flat panel CT following middle ear reconstruction: a study of 107 patients.

OBJECTIVES: After middle ear reconstruction using partial or total ossicular replacement prostheses (PORP/TORP), an air-bone gap (ABG) may persist because of prosthesis displacement or malposition. So far, CT of the temporal bone has played the main role in the diagnosis of reasons for postoperative insufficient ABG improvement. Recent experimental and clinical studies have evaluated flat panel CT (fpCT) as an alternative imaging technique that provides images with high isovolumetric resolution, fewer metal-induced artefacts and lower irradiation doses. METHODS: One hundred and seven consecutive patients with chronic otitis media with or without cholesteatoma underwent reconstruction by PORP (n = 52) or TORP (n = 55). All subjects underwent preoperative and postoperative audiometric testing and postoperative fpCT. RESULTS: Statistical evaluation of all 107 patients as well as the sole sub-assembly groups (PORP or TORP) showed a highly significant correlation between hearing improvement and fpCT-determined prosthesis position. FpCT enables detailed postoperative information on patients with middle ear reconstruction. CONCLUSIONS: FpCT is a new imaging technique that provides immediate feedback on surgical results after reconstructive middle ear surgery. Specific parameters evaluated by fpCT may serve as a predictive tool for estimated postoperative hearing improvement. Therefore this imaging technique is suitable for postoperative quality control in reconstructive middle ear surgery. KEY POINTS: • Flat panel CT offers advantages with regard to artefacts and radiation dose. • FpCT provides higher isovolumetric resolution of temporal bone and middle ear implants. • FpCT allows prediction of the postoperative hearing outcome in patients. • FpCT is an important tool for immediate postoperative quality control. • FpCT improves postoperative management of patients with complications following ossicular replacement.

[Quality control following reconstructive middle ear surgery: from bench to bedside]. / Qualitätssicherung nach rekonstruktiver Mittelohrchirurgie : Von der Studie zur Praxis.

BACKGROUND: The ongoing improvement of imaging quality nowadays focuses increasingly more on immediate quality evaluation of surgical measures. METHODS: Rotational tomography (RT) has been experimentally proven to be an alternative imaging technique to computed tomography (CT) in terms of quality and postoperative localization of middle ear implants in temporal bones. Based on these results imaging parameters were determined in the form of a surgical check list in order to systematically check individual but important surgical reconstructive steps. RESULTS: The positive benefit of RT concerning immediate and significant postoperative quality control was confirmed by a patient study. The surgical check list was successfully implemented under clinical framework requirements. Among these standardized parameters the determined angulation of inserted middle ear implants was given outstanding significance due to the predictive value concerning functional outcome. CONCLUSION: The RT procedure has been proven to be a reliable imaging tool for postoperative quality control following reconstructive middle ear surgery.

[Genetics of pheochromocytoma]. / Genetik der Phäochromozytome.

About one third of all patients with a pheochromocytoma are carriers of germ line mutations of 1 of the 10 susceptibility genes. Thus, these patients can be diagnosed and classified with specific tumor syndromes. This group is composed of the entities of multiple endocrine neoplasia type 2 (MEN2) due to mutations in the RET gene, von Hippel-Lindau disease (VHL, VHL gene), the paraganglioma syndromes types 1-4 (PGL1-4) due to mutations of the genes SDHD, SDHAF2, SDHC, SDHB, neurofibromatosis type 1 (NF1) due to mutations of the NF1 gene and familial pheochromocytoma syndromes due to mutations of the SDHA, TMEM127 and MAX genes. Patients with hereditary pheochromocytomas run a lifelong risk of relapse of pheochromocytoma. In addition extraparaganglial tumors are frequent and include medullary thyroid carcinoma in MEN2 or renal cancer or neuroendocrine pancreatic cancer as well as hemangioblastomas of the retina and the central nervous system in VHL. Furthermore, renal cancer may be associated with PGL4 and PGL3. In conclusion, molecular genetic screening is essential for the diagnosis of pheochromocytoma-associated cancer syndromes and is thus the cornerstone for successful lifelong preventive medicine of such patients and their relatives.

Flat panel CT following stapes prosthesis insertion: an experimental and clinical study.

OBJECTIVES: Anatomical information of the middle and inner ear is becoming increasingly important in post-operative evaluation especially after stapesplasty with unsuccessful improvement of the air-bone gap (ABG). So far computed tomography (CT) has been the first choice for detection of reasons for recurrent hearing loss. CT has the disadvantage of metal-induced artefacts after insertion of middle ear implants and of a relatively high irradiation dose. METHODS: Flat panel CT (fpCT) was performed in three temporal bone specimen after experimental insertion of different stapes prostheses, aiming to validate the accuracy of fpCT of the middle and inner ear. Additionally, 28 consecutive patients, supplied with different stapes prostheses underwent post-operative fpCT to compare the pre- and post-operative hearing results with the determined prosthesis position in the middle and inner ear. RESULTS: In all cases, fpCT showed a statistically significant correlation between hearing improvement and prosthesis position. This technique provided detailed post-operative information of the implant position in patients and temporal bone specimen. CONCLUSIONS: The new imaging technique of fpCT allows the immediate and almost artefact-free evaluation of surgical results following stapesplasty. Further benefits are a lower irradiation dose and higher isovolumetric resolution compared with standard CT. KEY POINTS: Flat panel computed tomography (fpCT) helps otosurgeons design precise stapes protheses. fpCT allows a prediction of the postoperative hearing outcome in patients. fpCT is an adequate imaging technique for immediate postoperative quality control. Postoperative management of patients with prosthesis-related complications is more appropriate.

[Large cystic tumor of the right neck]. / Große zystische Raumforderung zervikal rechts.

A 32-year-old patient presented to our department with a large cystic lesion in the right lateral neck (diameter 6 cm). After complete resection, the histopathological examination revealed a lymph node metastasis of a papillary thyroid carcinoma. We performed total thyroidectomy and bilateral selective neck dissection. There was a papillary microcarcinoma in the right lobe of the thyroid. The postoperative course was uneventful. Therapy with radioiodine was conducted. At 30 months after surgery the patient is free of disease.

[Evaluation of the Dresden Tympanoplasty Model (DTM)]. / Evaluation des Dresdner Tympanoplastik Modells (DTM).

The training of microsurgical motor skills is essentiell for surgical education if the interests of the patient are to be safeguarded. In otosurgery the complex anatomy of the temporal bone and variations necessitate a special training before performing surgery on a patient. We therefore developed and evaluated a simplified middle ear model for acquiring first microsurgical skills in tympanoplasty.The simplified tympanoplasty model consists of the outer ear canal and a tympanic cavity. A stapes model is placed in projection of the upper posterior tympanic membrane quadrant at the medial wall of the simulated tympanic cavity. To imitate the annular ligament flexibility the stapes is fixed on a soft plastic pad. 41 subjects evaluated the model´s anatomical analogy, the comparability to the real surgical situation and the general model properties the using a special questionnaire.The tympanoplasty model was very well evaluated by all participants. It is a reasonably priced model and a useful tool in microsurgical skills training. Thereby, it closes the gap between theoretical training and real operation conditions.

[Chondrosarcoma of the larynx. Experience gained in Freiburg since 1999]. / Chondrosarkome des Larynx. Freiburger Erfahrungen seit 1999.

BACKGROUND: Chondrosarcomas are rare tumors of the head and neck. Nevertheless, they display the most common non-epithelial malignancy of the larynx. MATERIALS AND METHODS: Between 1999 and February 2010 we treated six patients with laryngeal chondrosarcoma. The group included two female and four male patients ranging in age from 54 to 82 years. RESULTS: An 82-year-old female patient died 3 months after diagnosis and tracheostomy due to other underlying diseases. An 82-year-old male patient underwent primary radiation therapy. In the other patients, we performed a modified hemilaryngektomy in three cases and a laryngectomy in one. In those four cases, there were no signs of recurrent disease 50, 85, 87 and 95 months after surgery, respectively. There were no local or distant metastases. CONCLUSIONS: Chondrosarcomas of the larynx are slow growing neoplasms. Metastases occur in less than 3% of cases. Complete resection is the therapy of choice. Function-preserving surgical approaches should be favoured.

[Persistent extramedullary plasmacytoma of the nose after radiotherapy]. / Persistierendes extramedulläres Plasmozytom der Nase nach Radiatio.

Solitary extramedullary plasmacytomas of the head and neck are rare tumors. These tumors are known to be very radiosensitive and therefore radiotherapy is often considered as the treatment of choice. We present the case of a solitary extramedullary plasmacytoma of the nose which did not respond sufficiently to radiotherapy, i.e. persistence of the tumor led to surgical treatment. After a discussion of the recent literature we primarily recommend the excision of this type of tumor whenever possible.

Quality management in middle ear surgery: controversies regarding preoperative imaging.

Today a large variety of different imaging techniques are available for middle ear investigation. However, imaging is not suitable to give essential information in every case on the surgical strategy to be chosen. This article discusses the most frequent indications for preoperative imaging and the relevant techniques. CT scanning, MRI and rotational tomography are taken into consideration as well as traditional X-ray investigations like e.g. 'Schüller's view'. In general, preoperative imaging should only be performed in a patient if certain specific questions can be answered. The experience of the investigator to interpret the images may influence the choice of imaging as well as the equipment he has access to.

[Carcinoid of the middle ear. A case report]. / Das Karzinoid des Mittelohrs. Ein Fallbericht.

The case of a 47-year-old patient is described with a carcinoid of the middle ear. Initial symptoms were hearing impairment, feeling of pressure and dizziness. Mastoidectomy was carried out for mastoid shadowing with space encroachment in the auditory canal. The histological examination initially revealed an atypical cholesteatoma and the subsequent immunohistochemical investigation revealed a carcinoid. A radical excavation with complete excision of the tumor and tympanoplasty was carried out. A carcinoid of the middle ear is definitely a rare finding and the primary treatment is complete surgical removal. If metastases are suspected octreotide scintigraphy has proved to be the best option in analogy to intestinal carcinoids. Radiation therapy has not proved successful but the use of the somatostatin analog octreotide, interferon-alpha or palliative chemotherapy (e.g. streptozotosine, 5-fluorouracil) for metastases are further therapy options.

[Diagnostic value of color-coded Doppler sonography in neuro-otologic disorders]. / Wertigkeit der farbkodierten Duplexsonografie bei neuro-otologischen Krankheitsbildern.

PURPOSE: The successful introduction of Doppler and Color-Coded Doppler Sonography (CCDS) in the field of Otorhinolaryngology has improved the diagnostic sonographic value for several diseases of the head and neck region, e. g. in hemangiomas and vascular malformations. The diagnostic value of CCDS for examination of the extracranial brain supplying vessels in combination with neuro-otologic disorders is still under controversial discussion. MATERIALS AND METHODS: We investigated the diagnostic CCDS findings for 215 patients suffering from different neuro-otologic disorders. All patients were classified into 4 groups according to the different disorder entity (sudden deafness, tinnitus, vestibular neuropathy, combined diagnosis). The frequency of pathologic CCDS findings was correlated with the different groups using sonographic parameters such as atherosclerosis, stenosis and intima-media thickness. RESULTS: Classification of the disorder entities led to the following distribution: Sudden deafness group (85 patients; 40 %), Tinnitus group (44 patients; 20 %), Vestibular neuropathy group (41 patients; 19 %), Combined diagnosis group (45 patients; 21 %). Sonographic evaluation of atherosclerosis was possible in 76 cases (35 %), changes of the intima-media thickness were observed in 43 cases (20 %) while proof of stenoses was identified in 15 cases (7 %). The evaluation of plaque formation (atherosclerosis) in the sudden deafness group was significantly higher (p < 0.01) than in all other groups although the combined diagnosis group demonstrated certain tendencies (p < 0.08) without significant correlation. CONCLUSION: Our results reinforce the hypothesis of a vascular genesis of sudden deafness and seem to offer the possibility of sonographic differentiation between neuro-otologic disorder entities by use of CCDS. In contrast, it seems that the role of CCDS is negligible for individual diagnostic purposes.

[Conventional tomographic investigations of the reconstructed middle ear in temporal bone specimen]. / Röntgentomografische Untersuchungen des rekonstruierten Mittelohres am Felsenbeinpräparat.

BACKGROUND: In modern reconstructive middle ear surgery imaging plays an essential role as a diagnostic tool, especially in pre-operative planning. Nowadays imaging of surgical results as a matter of quality control in post-operative follow-up becomes more important. MATERIAL AND METHODS: Conventional tomography was performed in 10 temporal bone specimen using the CommCat IS 2000-system in order to evaluate anatomical structures and inserted middle ear prostheses (PORP/TORP). This imaging technique has not been used in middle ear surgery beforehand. RESULTS: Using conventional tomography characterization of anatomical structures of the temporal bone as e. g. the semicircular canals appeared to be of superior quality to comparable conventional radiographic imaging. Concerning imaging quality (contrast; resolution) conventional tomography allowed similar findings like computed tomography (CT)-scans in some of the investigated specimen while showing inferior sharpness quality due to technical reasons. Further advantages of conventional tomography in contrast to CT were the requirement of just 2.5 % of the CT's irradiation exposure, lack of metallic artefacts caused by implanted prostheses and the feasibility of distance- and angle-measurement of inserted prostheses towards the tympanic membrane which coincided extensively with the temporal bone preparation. CONCLUSIONS: Conventional tomography enables detailed anatomical imaging of the temporal bone region which outperforms conventional radiographic imaging, requires less irradiation dose than CT and helps avoid problems like metallic artefacts. This technique enhances immediate quality-control and seems to be therefore a promising tool for postoperative evaluation after reconstructive middle ear surgery.