[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.

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.

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.

[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.

[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.

Endoscopic sinus surgery training courses: benefit and problems - a multicentre evaluation to systematically improve surgical training.

BACKGROUND: The aim of this multicentre study was to systematically analyse the strengths and weaknesses in the surgical training for endoscopic sinus surgery (ESS) and identify measures that may improve training. METHODOLOGY: Using a structured questionnaire, 133 participants of ESS courses in seven centres in Germany, Switzerland and Australia were asked about their experiences during their dissection courses and how they perceived their course could be improved. RESULTS: Gaining confidence in handling of instruments and endoscopes was only a problem for participants with little experience in ESS. The majority of the participants, independent from their level of training, considered infundibulotomy and anterior ethmoidectomy as the easiest dissection steps, whilst surgery of the frontal sinus posed a considerable challenge for many surgeons even those with a higher level of training. Participants with and without ESS experience thought that emphasis on anatomy was the most important improvement that could be made during their surgical training. Virtually all participants stated that the course improved their anatomical knowledge, their surgical skills and their confidence when performing ESS. CONCLUSIONS: ESS dissection courses are considered beneficial by surgical trainees. Participants felt that more emphasis on sinus anatomy in conjunction with private study is essential to maximize their skills in surgical dissection. For beginners with ESS, an infundibulotomy and anterior ethmoidectomy were thought to be the best initial procedures to help develop endoscopic surgical skills.

[Advances in endoscopic diagnosis of dysplasia and carcinoma of the larynx]. / Fortschritte der endoskopischen Diagnostik von Dysplasien und Karzinomen des Larynx.

To improve the preoperative and intraoperative diagnosis of laryngeal cancer and its precursors, various endoscopic imaging techniques have been developed in recent years. These techniques differ markedly in their specific applications and goals. Precisely distinguishing among normal mucosa, dysplasia and invasive carcinoma with these procedures is necessary. Furthermore, the exact identification of tumor margins should be possible. The long-term goal is the development of optical biopsy. Since so far there have only been small studies regarding the evaluation of the presented methods, it is necessary to establish multi-center trials with large sample sizes to accurately estimate the value of these endoscopic imaging techniques.

[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.

Endoscopic measurements of free-flap perfusion in the head and neck region using red-excited Indocyanine Green: preliminary results.

BACKGROUND: Free-tissue transfer has become a standard procedure for reconstructive surgery in the head and neck area. Flap failures are relatively rare (or=64% for all other examinations. CONCLUSIONS: It was possible to prove the feasibility of endoscopic ICG fluorescence angiography in patients undergoing free-flap transfer to the UADT. The method provides instant information about the perfusion state of the tissue and is easily performed without greater patient discomfort or risk of side effects. Due to the endoscopic approach, the method seems highly promising for this indication and merits further evaluation.

[Anatomic variations of the sinuses; multiplanar CT-analysis in 641 patients]. / Anatomische Varianten der Nasennebenhöhlen; multiplanare CT-Analyse an 641 Patienten.

INTRODUCTION: The diagnostic workup proceeding paranasal sinus surgery routinely includes coronal CT views to get an exact representation of the microanatomy in the region of the lateral nasal wall and the anterior skull base. Axial and sagittal views are often not available, yet they can provide important additional information. STUDY DESIGN AND METHODS: It was the aim of the current study to analyse multislice CT data sets in order to determine the incidence of anatomical variants. The investigation was performed as a retrospective, monocentrical study on n = 641 patients. Prior paranasal sinus surgery was defined as the sole exclusion criterion. RESULTS: The analysis of the data showed the following anatomical variants of frontoethmoidal cells: Kuhn Typ I: 17.0 %, Typ II6.8 %, Typ III: 12.5 %, Typ IV: 0.1%. The prevalence for Agger nasicells was 80.0 %, that for supraorbital cells was 10.2 %, that for suprabullar cells was 28.2%, that for frontal bullae was 16.0% and the one for cells of the interfrontal septum was 11.9 %. The incidence of other anatomical variants was as follows: Concha Bullosain 22.2 %, Haller cells in 16.0 %, pneumatised Uncinate Process in 8.8% and Onodi Cells in 8.4 %. CONCLUSIONS: A multiplanar reconstruction of the frontoethmoidal complex with its numerous variants is essential in the preoperative workup of patients with conditions of the frontal sinus. This advantage can even be enhanced by using navigation systems, even though they are not available for every rhinosurgeon yet. However, navigation systems should not be considered as a surrogate for lacking anatomical knowledge.

Frontal sinus obliteration--a successful treatment option in patients with endoscopically inaccessible frontal mucoceles.

OBJECTIVE: This study evaluates non-standardized subjective patient satisfaction- and clinical outcome variables following frontal sinus obliteration with abdominal fat in endoscopically inaccessible mucoceles. METHODS: In a retrospective chart review, all patients who underwent frontal sinus obliteration for endoscopically inaccessible mucoceles at the Ludwig Maximilian University in Munich between 1996 and 2006 were identified and the postoperative outcomes were evaluated by a non-standardized patient questionnaire rating the degree of symptoms before and after surgery. Additionally, the postoperative clinical status and MRI-scans were analysed in a subgroup of patients. RESULTS: Nine out of 10 patients were generally satisfied with the obliteration. Most had a significant improvement in their main symptoms and reported a decrease in annual days of missed work and a reduced use of disease-specific drugs. The sense of smell and the intensity of postnasal dripping remained subjectively unchanged. Seventy percent of patients complained about temporary pain at the abdominal donor side. CONCLUSIONS: Based on these results, osteoplastic frontal sinus obliteration using abdominal fat seems to be a successful treatment option in patients in whom mucoceles of the frontal sinus are not endoscopically accessible.

Indirect fluorescence laryngoscopy in the diagnosis of precancerous and cancerous laryngeal lesions.

Indirect fluorescence endoscopy of the larynx has proven to facilitate the detection and delineation of precancerous and cancerous lesion. The different methods are easy to handle and can be performed on an outpatient basis. Early diagnosis of laryngeal cancer and its precursor lesions is simplified. The aim of the present study is to compare indirect autofluorescence laryngoscopy to 5-ALA-induced PPIX fluorescence laryngoscopy. In a prospective study, 56 patients with suspected precancerous or cancerous lesions were primarily investigated by indirect autofluorescence laryngoscopy. In a second step 5-ALA-NaCl (0.6%) was topically applied to the larynx by inhalation, and indirect fluorescence laryngoscopy repeated 2 h after application. Autofluorescence as well as 5-ALA-induced fluorescence was induced by filtered light (375-440 nm) of a xenon short arc lamp and processed by a CCD camera system (D-light-AF System, Storz, Tuttlingen, Germany). White-light and fluorescence images were digitally recorded, immediately assessed for diagnosis and finally compared to pathohistological findings. Inconspicuous laryngeal mucosa presented a typical green fluorescence signal in autofluorescence endoscopy, which turned blue during 5-ALA-laryngoscopy. Precancerous and cancerous lesions displayed a loss of autofluorescence in autofluorescence endoscopy whereas increased protoporphyrin IX fluorescence could be observed in 5-ALA laryngoscopy. Both imaging techniques were suitable to distinguish benign from precancerous or cancerous lesions. In contrast PPIX fluorescence was easily recognized in scarred vocal folds. According to our results, both non-invasive fluorescence imaging techniques are useful in the early diagnosis of laryngeal cancer. Moreover autofluorescence can be used immediately without drug application and possible side effects. 5-ALA-induced fluorescence seems to be more suited for diagnostic examination of mucosal lesions in recurrent precancerous and cancerous lesions after surgery.

[Cervical skin emphysema: a rare complication following tonsillectomy]. / Das zervikale Hautemphysem: Eine seltene Komplikation nach Tonsillektomie.

Emphysema of the subcutis or interstitial compartments of the neck or around the naso- oro- or hypopharynx is caused by a perforation. In most cases, it occurs after surgery in this area; spontaneous emphysema is very rare. The characteristic symptom is crepitation; the extension is best seen on a CT scan. Endoscopic control of the surgical area for other lesions is necessary. An anaerobic, gas producing infection must be ruled out. Antibiotics should be given prophylactically.

[Myxoma and myxoid chondrosarcoma of the nasal septum: two case reports]. / Myxomatöse Neoplasien des Nasenseptums: 2 Fallberichte.

Myxoid neoplasms are histopathologically divided into true myxomas and other tumors of myxomatous character. In the region of the nasal septum, this tumor entity is extremely rare. In the following two case reports, the unusual findings of a myxoma and a myxoid chondrosarcoma of the nasal septum are presented and discussed. At first visit, both patients reported a slowly progressing, bilateral nasal obstruction. In nasal endoscopy, both showed a smoothly surfaced, spheroid, soft tissue mass in the dorsal nasal septum. On CT-scans, a displacing growth was described for the first patient; in the second patient, a bony arrosion of the floor of the sphenoid sinus was suspected. Both lesions were surgically completely removed. The histopathological diagnosis was myxoma in the first and myxoid chondrosarcoma in the second patient. An early, locally recurrent tumor in the second patient could also be surgically removed. Both patients have been in full remission for more than a year. In spite of the similar symptoms and clinical findings, histopathologically different myxoid neoplasms of the nasal septum show marked variations in growth and recurrence.

[Adenocarcinoma in the tear sack after endonasal dacryocystorhinostomy]. / Adenokarzinom des Tränensackes nach endonasaler Dakryozystorhinostomie.

Primary adenocarcinoma of the nasolacrimal drainage system is a highly uncommon diagnosis, which is presumably derived from malignantly transformed glandular cells that are interspersed amongst the epithelium of the nasolacrimal duct. The patients usually present with unspecific orbital or sinus-nasal symptoms. An appropriate therapeutic regime consists of a preferably early, radical resection and local postoperative radiation therapy. This brief contribution deals with an especially uncommon case of a carcinoma of the nasolacrimal drainage system. On his first presentation, the 62-year old patient complained about right sided epiphora which had been present over the last few weeks. Eight years prior to presentation, he had been treated for a nasolacrimal duct stenosis by endoscopic dacryocystorhinostomy on this side. Diagnostic imaging revealed a soft tissue mass in the right nasolacrimal duct which was removed by a combined extra-endonasal approach. The final histopathological evaluation was adenocarcinoma. Following postoperative radiotherapy, the patient has been free of disease for 42 months. The occurrence of adenocarcinoma of the nasolacrimal drainage system in the setting of previous surgery may provide a new insight into the clinical spectrum of the natural history of this disease.