[Skull base surgery in the German DRG system-New categorization of important procedures]. / Die Schädelbasischirurgie im deutschen DRG-System ­ Neue Zuordnung wichtiger Prozeduren.

Surgery of the skull base includes interventions between the nose or paranasal sinuses (anterior skull base) or ear/temporal bone (lateral skull base) and the intracranial space. As interventions at the anterior skull base almost exclusively involve complex pathologies in a demanding anatomical region, in many cases two experienced surgeons from different disciplines are required who should be experienced in operating together. The technical and time requirements are also considerable in many cases; however, for many procedures there are no specific skull base operational and procedural keys (OPS) codes that take the considerable personnel and structural effort into account. A change in the diagnosis-related groups (DRG) system, implemented since the beginning of 2023, now adjusts the remuneration of the abovementioned effort for malignant pathologies of the anterior and lateral skull base. The reallocation of procedures 5­015.0/1/3/4 and 5­016.0/2/4/6 results in a significant upgrade of anterior and lateral skull base surgery. Since the beginning of 2023 skull base surgery will no longer be charged under DRG D25C with a (former) relative weight of 1.893, but with DRG D25B with a current relative weight of 3.753 when a code of the aforementioned groups is used. Nevertheless, further adjustments are necessary, for example, in the available reconstructive steps in order to provide the Institute for the Remuneration System in Hospitals (InEK) with the most differentiated data possible on the procedural effort of the intervention and to achieve a more balanced distribution of the reimbursements of skull base surgery in the long term.

[Radiation or Surgery for HPV-positive oropharyngeal cancer? The ORATOR2 Trial - Comparing apples and oranges]. / Strahlentherapie oder Operation bei HPV-positiven Oropharynxkarzinomen? Die ORATOR2-Studie ­ ein Vergleich von Birnen und Äpfeln.

ORATOR2 was a randomized phase II trial aiming to assess an optimal approach for therapy de-escalation in early (T1-T2, N0-N2) human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC). Radiotherapy (RT) (consisting of a reduced dose of 60 Gy with concurrent weekly cisplatin in N+ patients) was compared to trans-oral surgery (TOS) and neck dissection (ND) (with adjuvant reduced-dose RT depending on pathologic findings) in 61 patients. The primary endpoint, overall survival, favored the radiotherapy approach. This was mainly due to 3 mortality events in the surgery arm (2 surgery-related) which resulted in an early trial termination. The authors, who speak on behalf of the German Society of Otorhinolaryngology, Head & Neck Surgery (working group for oncology) warn to draw conclusions for clinical practice pointing out the main shortages/weaknesses of this trial especially in the surgery arm (at least 1 cm margins, recommending re-operation if not achieved, prohibition of regional or free flaps, high rates of tracheotomy, low rate of TLM). Small patient numbers, a highly selected patient cohort and a short follow-up time further limit this study's relevance. Therefore, patients with HPV-related OPSCC should not receive de-escalating (radiation) therapy outside of clinical trials. When deciding between a surgical or a radio-therapeutical approach, patients should be informed about the pros and cons of both modalities after interdisciplinary consent in a tumor board, as long as clinical trial results` (e. g. EORTC 1420) are pending.

[Treatment of head and neck squamous cell carcinoma recurrences and distant metastases : Highlights of the 2019 ASCO Meeting]. / Therapie der rezidivierten und fernmetastasierten Plattenepithelkarzinome des Kopf-Hals-Bereichs : Highlights des ASCO-Meetings 2019.

BACKGROUND: The contributions presented at this year's ASCO conference on treatment of recurrent or metastatic head and neck squamous cell carcinoma (R/M-HNSCC) focused on systemic therapies, as in recent years. Two phase III studies-TPExtreme and Keynote-048-are expected to change clinical practice in first-line treatment of R/M-HNSCC. MATERIALS AND METHODS: Abstracts and presentations from this year's ASCO Annual Meeting on R/M-HNSCC were screened and checked for clinical relevance. RESULTS: TPExtreme, a randomized phase III trial, could show less toxicity and similar overall survival in patients treated with docetaxel, cisplatin, and cetuximab (TPEx regimen) compared to standard first-line therapy with the Extreme regimen (cisplatin, 5­fluorouracil [5-FU], cetuximab), albeit failing its endpoint of significantly improved survival. The randomized phase III Keynote-048 study could show a significant survival benefit in all patients treated with pembrolizumab, 5­FU, and cis-/carboplatin compared to Extreme. When selected patients (PD-L1 CPS ≥1 and ≥20) were treated with pembrolizumab monotherapy, they showed increased overall response rates in contrast to patients treated with Extreme. CONCLUSION: Based on the results of Keynote-048, pembrolizumab ± chemotherapy gained FDA approval as first-line treatment for R/M-HNSCC in the USA. Approval in Europe is expected soon and will probably have a strong impact on clinical routine.

[New aspects in thyroid cancer treatment : Highlights of the 2019 ASCO Annual Meeting]. / Neue Aspekte in der Behandlung von Schilddrüsenkarzinomen : Highlights vom ASCO-Kongress 2019.

The majority of patients with thyroid cancer have a remarkably good chance of cure in the context of surgical treatment, due to their mostly local tumor spread. However, a small proportion of patients with advanced and metastatic thyroid tumors usually require multimodality treatment. Abstracts from the 2019 American Society of Clinical Oncology (ASCO) Annual Meeting are summarized in this review, to provide insights into current aspects of thyroid carcinoma treatment. In addition to innovations in the treatment of radioiodine-refractory differentiated and medullary thyroid carcinoma, current approaches to anaplastic thyroid carcinoma are presented and critically interpreted.

Nutrition management for head and neck cancer patients improves clinical outcome and survival.

Up to 80% of patients with head and neck cancers are malnourished because of their lifestyle and the risk factors associated with this disease. Unfortunately, nutrition management systems are not implemented in most head and neck cancer clinics. Even worse, many head and neck surgeons as well as hospital management authorities disregard the importance of nutrition management in head and neck cancer patients. In addition, the often extensive resection and reconstruction required for tumors in the upper aerodigestive tract pose special challenges for swallowing and sufficient food intake, placing special demands on nutrition management. This article presents the basics of perioperative metabolism and nutrition management of head and neck cancer patients and makes recommendations for clinical practice. Implementing a nutrition management system in head and neck cancer clinics will improve the clinical outcome and the survival of the patients.

Buried free flaps in head and neck reconstruction: higher risk of free flap failure?

Thrombosis of the pedicle is central to free flap failure, and early revision of a compromised flap is the key to successfully salvage a flap. Therefore, the majority of free flaps in reconstructive head and neck surgery are used with the ability to visually examine the flap. Sometimes, due to intra-operative circumstances, it is necessary to use a flap that cannot be monitored externally. These flaps are called buried flaps and have the reputation of being put at risk. The current literature provides only limited data to support or disprove this position. A single institution retrospective review of patient charts between 2007 and 2015 was performed. Flap monitoring was carried out with hand-held Doppler of the pedicle hourly for the first 72 h in all cases. Additional duplex ultrasound was performed in the majority of buried flaps. A total of 437 flaps were included into the study. 37 flaps (7.8 %) were identified to fulfill the criteria of a buried free flap. In total, four patients had complications, three of which required operative reexploration. All interventions were successful, resulting in no flap loss in our series. An accurate operation technique combined with meticulous monitoring protocols supported by duplex ultrasound can result in satisfactory outcome of buried flaps. No enhanced risk of flap loss of buried flaps was found in our cohort.

Narrow band imaging for early diagnosis of epithelial dysplasia and microinvasive tumors in the upper aerodigestive tract.

The various stages of tumor growth are characterized by typical epithelial, vascular, and secondary connective tissue changes. Narrow Band Imaging (NBI) endoscopy is a minimally invasive imaging technique that presents vascular structures in particular at a higher contrast than white light endoscopy alone. In combination with high-resolution image recording and reproduction (high-definition television, HDTV; ultra-high definition, 4K), progress has been made in otolaryngological differential diagnostics, both pre- and intraoperatively. This progress represents an important step toward a so-called optical biopsy. Flexible endoscopy in combination with NBI allows for a detailed assessment of areas of the upper aerodigestive tract that are difficult to assess by rigid endoscopy. Papillomas along with precancerous and cancerous lesions are characterized by epithelial and connective tissue changes as well as by typical perpendicular vascular changes. Systematic use of NBI is recommended in the differential diagnosis of malignant lesions of the upper aerodigestive tract. NBI also offers a significant improvement in the pre- and intraoperative assessment of superficial resection margins. In particular, the combination of NBI and contact endoscopy (compact endoscopy) facilitates excellent therapeutic decisions during tumor surgery. Intraoperative determination of resection margins at an unprecedented precision is possible. In addition, assessment of the form and extent of the perpendicular vessel loops stimulated by epithelial signaling enables differential diagnostic decisions to be made, approximating our goal of an optical biopsy.

Diagnosis of upper aerodigestive tract tumours using autofluorescence endoscopy in south east asian patients.

Diagnosis of upper aerodigestive tract tumours using autofluorescence endoscopy in south east asian patients. OBJECTIVES: Autofluorescence is a highly sensitive, and specific, complementary diagnostic tool for the photodiagnosis of head and neck squamous cell carcinomas. Together with ease of use, these properties suggest that autofluorescence, used alongside white light endoscopy, could be a promising tool for the screening of high-risk populations. The aim of this study was to evaluate its effectiveness in detecting tumours involving the upper aerodigestive tract, in comparison with histopathologic examination. METHODOLOGY: A cross-sectional prospective study was carried out from June 2011 till March 2012. Forty-five patients with clinical evidence of suspicious lesions involving the upper aerodigestive tract were enrolled and examined using conventional white light, and autofluorescence endoscopy. A biopsy of each lesion was subsequently submitted for histopathologic examination. RESULTS: Using histology as our gold standard, we compared the sensitivity, specificity, and predictive values of autofluorescence endoscopy in detecting upper aerodigestive tract tumours. In comparison to histopathologic examination, the sensitivity of autofluorescence endoscopy was 95%, with a specificity of 74% (P value<0.001). The positive and negative predictive values were 78%, and 94% respectively. These data confirm a statistically significant correlation between autofluorescence and histopathologic diagnoses. CONCLUSIONS: Autofluorescence endoscopy was effective in detecting upper aerodigestive tract tumours, with excellent discrimination between benign and malignant phenotypes; this methodology is an ideal adjunct to white light endoscopy.

[Fluorescence imaging in laryngology: Physical principles, clinical applications and study results]. / Fluoreszenzbildgebung in der Laryngologie: Physikalische Grundlagen, klinische Anwendung und Studienergebnisse.

BACKGROUND: Early detection and adequate preoperative assessment of neoplastic lesions of the larynx allow for voice-preserving therapy concepts. OBJECTIVE: The physical principles, clinical applications and most important study results of fluorescence imaging are presented. MATERIALS AND METHODS: The entire literature on autofluorescence endoscopy of the larynx was analysed and compared to induced fluorescence endoscopy. RESULTS: In detecting malignant and premalignant lesions of the larynx, autofluorescence endoscopy shows a significantly higher sensitivity, specificity and accuracy than white light endoscopy alone. Induced fluorescence endoscopy achieved an even higher sensitivity, albeit at the expense of specificity. CONCLUSION: Autofluorescence endoscopy represents a simple screening procedure for early detection of laryngeal cancer and its precursor lesions, whereas induced fluorescence endoscopy is more suited for the identification of recurrent disease.

[Noninvasive imaging using autofluorescence endoscopy: Value for the early detection of laryngeal cancer]. / Nichtinvasive Bildgebung mittels Autofluoreszenzendoskopie: Stellenwert bei der Früherfassung des Kehlkopfkarzinoms.

BACKGROUND: Autofluorescence endoscopy is able to delineate malignancy from normal tissue by color change. The objective of the present study was to assess the value of this noninvasive imaging method for the early detection of laryngeal cancer and its precursor lesions. PATIENTS AND METHODS: In a prospective study, 152 patients with a laryngeal lesion who were undergoing microlaryngoscopy were investigated. Autofluorescence endoscopy was performed after conventional white light endoscopy, just before excisional biopsy was carried out for histologic verification. RESULTS: In the early detection of laryngeal cancer and its precursor lesions, autofluorescence endoscopy showed a significantly higher sensitivity (98 vs. 88%) and accuracy (97 vs. 90%) than white light endoscopy alone, whereas the specificity (97 vs. 93%) was essentially equal in both methods. CONCLUSION: Autofluorescence endoscopy qualifies as a simple screening procedure for rapid detection of suspicious lesions and assessment of their horizontal extension. This allows for guided biopsy or tumor resection, and can also be used in oncological follow-up.

[Optical coherence tomography for early diagnosis of epithelial dysplasia and microinvasive carcinoma of the upper aerodigestive tract]. / Optische Kohärenztomographie zur Früherkennung epithelialer Dysplasien und mikroinvasiver Karzinome im oberen Luft-Speise-Weg.

BACKGROUND: Gold standard in the evaluation of upper aerodigestive tract (UADT) lesions is white light endoscopy followed by invasive tissue biopsy. This procedure is time consuming and expensive. Optical coherence tomography (OCT) is a noninvasive method, which provides high resolution, cross-sectional images of superficial tissue layers in real time. OBJECTIVE: This article aims to present a contemporary and comprehensive review on the role of OCT in differentiating between epithelial dysplasias and early invasive carcinomas of the UADT. MATERIALS AND METHODS: PubMed was searched using "optical coherence tomography/larynx" and other appropriate search strings in August 2015. RESULTS: OCT enables differentiation between benign, premalignant, and early malignant lesions of the UADT with high sensitivity and specificity. In addition, OCT holds promise as a clinical tool for guidance of surgical biopsies, follow-up of recurrent lesions, and for demarcation of tumor margins. Inadequate evidence and technical limitations hamper implementation of OCT into clinical routine. CONCLUSION: If the aforementioned problems are successfully solved, OCT seems to have the potential to substantially improve both diagnosis and management of precancerous and early cancerous lesions of the UADT.

[Optical diagnostic methods for early tumour diagnosis in the upper aerodigestive tract: Quo vadis?]. / Optische Diagnoseverfahren zur Tumorfrühdiagnostik im oberen Luft-Speise-Weg: Quo vadis?

BACKGROUND: Optical diagnostic methods may simplify and improve the early diagnosis of tumours of the upper aerodigestive tract; however, these have not yet found their way into clinical routine. OBJECTIVE: This article aims to define the problems that have prevented routine use of optical diagnostic methods so far, as well as listing and also explaining potential trendsetting approaches to overcome these difficulties. MATERIALS AND METHODS: The study is based on a combined analysis of publically accessible databases (PubMed MEDLINE, Thompson Reuters Web of Science, SPIE. Digital Library; full time period available; search strings: "oral cavity", "pharynx", "larnyx", "optical diagnosis", "optical biopsy", "optical coherence tomography", "confocal endomicroscopy", "fluorescence endoscopy", "narrow band imaging", "non-linear imaging", "fluorescence lifetime imaging"), as well as personal experiences. RESULTS: Both conceptual and methodical problems were determined, and possible solutions based on current developments are discussed. CONCLUSION: Optical diagnostic methods have the potential to revolutionise early diagnosis of upper aerodigestive tract malignancies, providing the different hurdles listed in this review can be overcome.

[Narrow band imaging for early diagnosis of epithelial dysplasias and microinvasive tumors in the upper aerodigestive tract]. / "Narrow band imaging" zur Früherkennung epithelialer Dysplasien und mikroinvasiver Karzinome im oberen Luft-Speise-Weg.

The various stages of tumor growth are characterized by typical epithelial, vascular, and secondary connective tissue changes. Narrow band imaging (NBI) endoscopy is a minimally invasive imaging technique that presents vascular structures in particular at a higher contrast than white light endoscopy alone. In combination with high-resolution image recording and reproduction (high-definition television, HDTV; ultra-high definition, 4K), progress has been made in otolaryngological differential diagnostics, both pre- and intraoperatively. This progress represents an important step towards a so-called optical biopsy. Flexible endoscopy in combination with NBI allows detailed assessment of areas of the upper aerodigestive tract which are difficult to assess by rigid endoscopy. Papillomas, precancerous, and cancerous lesions are characterized by epithelial and connective tissue changes, as well as by typical perpendicular vascular changes. Systematic use of NBI is recommended in the differential diagnosis of malignant lesions of the upper aerodigestive tract. NBI also convinces by a significant improvement in pre- and intraoperative assessment of superficial resection margins. In particular, the combination of NBI and contact endoscopy (compact endoscopy) permits excellent therapeutic decisions during tumor surgery. Intraoperative determination of resection margins at unprecedented precision is possible. In addition, assessment of the form and extent of the perpendicular vessel loops stimulated by epithelial signaling enables differential diagnostic decisions to be made, approximating our goal of an optical biopsy.

[Bone Necrosis of the Hand]. / Knochennekrosen der Hand.

The bone necrosis of the hand is a common disease of the bone-cartilage complex. In principle, every bone of the hand can be affected. Compared to other osteonecroses of the hand the necrosis of the lunate occurs most frequently. Other diseases such as osteonecrosis of the Os scaphoideums (Morbus Preiser) are much rarer. Unfrequent diseases such as osteonecrosis of the metacarpal heads or all carpal bones are restricted to case descriptions. The lunate osteonecrosis leads to osteoarthritis of the wrist if untreated. A detailed clinical examination and adequate radiological diagnosis are essential. The lunate osteonecrosis is classified according to Lichtman and Ross based on radiographs. The treatment is being executed either conservatively or surgically, depending on the stage. In surgical treatment pressure relieving and revascularization procedures and rescue operations have been established. For all other osteonecroses of the hand no standardized therapy can be assigned because sufficient data are not available. Generally, the treatment for bone necroses of the hand should be found for each patient individually.

Sinonasal outcomes following endoscopic anterior skull base surgery with nasoseptal flap reconstruction: a prospective study.

OBJECTIVE: To assess nasal morbidity resulting from nasoseptal flap use in the repair of skull base defects in endoscopic anterior skull base surgery. METHODS: Thirty-six patients awaiting endoscopic anterior skull base surgery were prospectively recruited. A nasoseptal flap was used for reconstruction in all cases. Patients were assessed pre-operatively and 90 days post-operatively via the Sino-Nasal Outcome Test 20 questionnaire and visual analogue scales for nasal obstruction, pain, secretions and smell; endoscopic examination findings and mucociliary clearance times were also recorded. RESULTS: Sino-Nasal Outcome Test 20 questionnaire data and visual analogue scale scores for pain, smell and secretions showed no significant differences between pre- and post-operative outcomes, with visual analogue scale scores for nasal obstruction actually showing a significant improvement (p = 0.0007). A significant deterioration for both flap and non-flap sides was demonstrated post-operatively on endoscopic examination (p = 0.002 and p = 0.02 respectively). CONCLUSION: Whilst elevation of a nasoseptal flap in endoscopic surgery of the anterior skull base engendered significant clinical deterioration on examination post-operatively, quality of life outcomes showed that no such deterioration was subjectively experienced by the patient. In fact, there was significant nasal airway improvement following nasoseptal flap reconstruction.

[The supraclavicular flap for reconstruction of the head and neck]. / Der supraclaviculäre Lappen zur Rekonstruktion im Kopf-Hals-Bereich.

The complex anatomy of the head and neck region requires the ability to raise a wide spectrum of pedicled and free flaps, to ensure optimal reconstruction of various defects by the reconstructive surgeon. The supraclavicular (island) flap, which has almost been buried in oblivion, provides excellent potential to reconstruct even bigger defects of the head and neck region, while causing minimal donor site morbidity at the same time. Its benefits lie in the reliable skin island and its wide arc of rotation, resulting in excellent cosmetic and functional outcomes.

[Genetics of congenital aniridia]. / Genetik der kongenitalen Aniridie.

BACKGROUND: Mutations in the PAX6 gene mostly cause non-syndromic aniridia with autosomal dominant inheritance and familial occurrence. The underlying point mutations and deletions in the PAX6 locus cause loss-of-function of one gene copy (haploinsufficiency). Mutations with residual PAX6 function often result in milder disease expression but may also cause distinct and more severe ocular phenotypes. Combined deletion of PAX6 and the adjacent WT1 tumor suppressor gene causes Wilms tumor, aniridia, genitourinary anomalies and mental retardation (WAGR) syndrome with a high risk for Wilms tumors in infancy. PURPOSE: Genetic diagnostics are important for confirming the clinical diagnosis, for the assessment of the risk of recurrence and early recognition of children with associated tumor risk. RESULTS AND DISCUSSION: Sequencing of the PAX6 gene and quantitative analysis of the PAX6 locus allow for efficient molecular genetic evaluation of the clinical diagnosis of both isolated and syndromic aniridia. In cases of clinical overlap with other entities, high-throughput sequencing of multiple additional genes can simultaneously cover genes for differential diagnoses (e.g. microphthalmia syndromes). Optimal care of aniridia patients requires close cooperation of ophthalmologists and medical geneticists.

Complications in endonasal sinus surgery: a 5-year retrospective study of 2,596 patients.

Recent developments should have aided to reduce postoperative complications of endoscopic sinonasal surgery: Computerised tomography (CT) and magnetic resonance imaging (MRI) allow a more precise preoperative view of the anatomic situation and possible variations. The Lund-MacKay-Index provides a tool to assess the extent of the disease, and by introducing microscopic-endonasal and computer-assisted sinunasal surgery (CAS) as well as providing the corresponding training technical progress has been made. We analysed the data of 2,596 patients with acute or chronic rhinosinusitis who underwent surgery between 2000 and 2005 using the procedure of Stammberger. We saw 3.1 % minor complications (minor bleedings, perforation of the lamina papyracea), 0.9 % major complications (severe bleedings, cerebrospinal fluid (CSF) leaks, lesion of the ductus lacrimalis), and one (0.04 %) serious complication (meningitis). When we compared these figures with those of reports from the late 90 s by correlating opacification, type of operation, the surgeon's experience and employing CAS with the outcome we did not find a distinct improvement in the rate of postoperative complications. Serious complications and those resulting in permanent harm such as carotid artery injury, cerebral deficit or death have, however, become very rare. A grading into I (minor), II (major) and III (serious) complications is proposed, to point out this critical grade-III proportion, which should not exceed 0.1 %.