[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.

Induction chemotherapy (IC) followed by radiotherapy (RT) versus cetuximab plus IC and RT in advanced laryngeal/hypopharyngeal cancer resectable only by total laryngectomy-final results of the larynx organ preservation trial DeLOS-II.

Background: The German multicenter randomized phase II larynx organ preservation (LOP) trial DeLOS-II was carried out to prove the hypothesis that cetuximab (E) added to induction chemotherapy (IC) and radiotherapy improves laryngectomy-free survival (LFS; survival with preserved larynx) in locally advanced laryngeal/hypopharyngeal cancer (LHSCC). Patients and methods: Treatment-naïve patients with stage III/IV LHSCC amenable to total laryngectomy (TL) were randomized to three cycles IC with TPF [docetaxel (T) and cisplatin (P) 75 mg/m2/day 1, 5-FU (F) 750 mg/m2/day days 1-5] followed by radiotherapy (69.6 Gy) without (A) or with (B) standard dose cetuximab for 16 weeks throughout IC and radiotherapy (TPFE). Response to first IC-cycle (IC-1) with ≥30% endoscopically estimated tumor surface shrinkage (ETSS) was used to define early responders; early salvage TL was recommended to non-responders. The primary objective was 24 months LFS above 35% in arm B. Results: Of 180 patients randomized (July 2007 to September 2012), 173 fulfilled eligibility criteria (A/B: larynx 44/42, hypopharynx 41/46). Because of 4 therapy-related deaths among the first 64 randomized patients, 5-FU was omitted from IC in the subsequent 112 patients reducing further fatal toxicities. Thus, IC was TPF in 61 patients and TP in 112 patients, respectively. The primary objective (24 months LFS above 35%) was equally met by arms A (40/85, 47.1%) as well as B (41/88, 46.6%). One hundred and twenty-three early responders completed IC+RT; their overall response rates (TPF/TP) were 94.7%/87.2% in A versus 80%/86.0% in B. The 24 months overall survival (OS) rates were 68.2% and 69.3%. Conclusions: Despite being accompanied by an elevated frequency in adverse events, the IC with TPF/TP plus cetuximab was feasible but showed no superiority to IC with TPF/TP regarding LFS and OS at 24 months. Both early response and 24 months LFS compare very well to previous LOP trials and recommend effective treatment selection and stratification by ETSS. Clinical trial information: NCT00508664.

Distinct patterns of chromosomal alterations in high- and low-grade head and neck squamous cell carcinomas.

Comparative genomic hybridization was performed on 30 primary head and neck squamous cell carcinomas. Fractional or entire DNA loss of chromosome 3p was a basic finding that occurred in 29 cases (97%). Additional DNA underrepresentations were observed in more than 50% of the cases on chromosomes 1p, 4, 5q, 6q, 8p, 9p, 11q, 13q, 18q, and 21q. Deletions on chromosomes 3p, 13q, and 17p were confirmed by loss of heterozygosity analysis. Entire or partial DNA copy number increases were identified for chromosome 3q in 26 cases (87%) with high-level amplifications at 3q24 and 3q27-qter. Overrepresentations were found in decreasing order of frequency at 11q13 (70%), 8q (57%), 19q (50%), 19p (47%), and 17q (47%). The use of comparative genomic hybridization superkaryograms of the group of well-differentiated carcinomas (G1) indicated that the deletions on chromosomes 3p and 9p along with the overrepresentation of 3q are associated with early tumor development. Accordingly, the undifferentiated tumors (G3) were characterized by additional deletions on chromosomes 4q, 8p, 11q, 13q, 18q, and 21q and overrepresentations on 1pter, 11q13, 19, and 22q, suggesting that these changes are preferentially associated with tumor progression.

Patterns of chromosomal alterations in metastasizing and nonmetastasizing primary head and neck carcinomas.

In an attempt to define chromosomal alterations that are associated with the metastatic phenotype, we investigated a total of 29 metastasizing (pN+) and 19 non-metastasizing (pN0) head and neck squamous cell carcinomas by comparative genomic hybridization (CGH). The analysis indicated that the pN0 tumors carried preferentially overrepresentations of chromosomes 5p, 6p, and 7p and that the pN+ tumors were frequently characterized by deletions on chromosomes 7q, 10q, 11p, 11q, 15q, and 20p and overrepresentations of the chromosomes 19q and 20q. In particular, the use of difference histograms and statistical analysis indicated that the deletions on chromosomes 10q25-q26 and 11p13-p14 were highly significant for metastasizing carcinomas. The findings on chromosome 10q were supported by loss of heterozygosity analysis in the primary tumors and eight synchronous lymph node metastases using four microsatellite polymorphisms. The data suggest that distinct patterns of genetic lesions are responsible for the metastatic phenotype of head and neck squamous cell carcinomas.

Distinct regions of allelic imbalance on chromosome 10q22-q26 in squamous cell carcinomas of the lung.

The genetic mechanisms underlying the progression to the metastatic phenotype of lung cancer are poorly understood. We recently showed that small cell lung cancer (SCLC) and metastasizing squamous cell carcinomas are characterized by an increased incidence of allelic loss on chromosome 10q. In the present study we performed a deletion mapping using 24 polymorphic markers on chromosome 10q22-q26 in 39 squamous cell carcinomas (SCC) of the lung identifying 14 metastatic carcinomas (74%) and three non-metastatic SCC (15%) with allelic imbalance. The allelotype analysis indicated three regions of allelic loss that were clustered at the loci Afm086/D10S541, D10S185 and D10S1782/D10S169. A localized microsatellite instability was observed in two carcinomas for the markers D10S1686 and D10S1782. In addition the PTEN/MMAC1 gene was analysed by direct DNA sequencing and Southern blot analysis in 25 and 28 carcinomas, respectively, without detecting any genomic alterations. Similarly, no altered transcript was detected in 15 tumor cell lines and 20 primary tumors by Northern blot analysis or RT-PCR. In summary, three distinct regions of allelic imbalance were identified suggesting that multiple tumor suppressor genes on chromosome 10q contribute to tumor progression and metastases formation of lung cancer.

The glutathione S-transferase GSTP1 polymorphism: effects on susceptibility to oral/pharyngeal and laryngeal carcinomas.

We have examined the hypothesis that the polymorphic, glutathione S-transferase GSTP1 gene is a susceptibility candidate for squamous cell cancer of the oral/pharynx and larynx. We describe GSTP1 genotype frequencies in 380 cases and 180 controls. We found a lower frequency of GSTP1 AA in the oral/pharyngeal cases compared with controls (p = 0.003, odds ratio = 0.47) after correction for age and gender. We used an immunohistochemical approach to show widespread expression of the GSTP1 subunit throughout the pharynx and larynx. In uninfiltrated tissue, strong positivity was found throughout the squamous cell epithelium with the exception of the basal cell layer. The cilia of the respiratory epithelium of the larynx also showed positivity for GSTP1. In tumour tissue, expression of GSTP1 was similar in pharyngeal and laryngeal samples. These data are the first to show that polymorphism at GSTP1 mediates susceptibility to squamous cell cancer of the upper aerodigestive tract. No significant interactions were identified between GSTP1 and GSTM1, GSTM3, GSTT1 and the cytochrome P450 CYP1A1, CYP2D6 and CYP1A1 genotypes.

Polymorphism in cytochrome P450 CYP2D6, CYP1A1, CYP2E1 and glutathione S-transferase, GSTM1, GSTM3, GSTT1 and susceptibility to tobacco-related cancers: studies in upper aerodigestive tract cancers.

Glutathione S-transferase GSTM1, GSTM3 and GSTT1 and cytochrome P450 CYP2D6, CYP1A1 and CYP2E1 loci are susceptibility candidates for cancers of the upper aerodigestive tract because putatively protective and risk genotypes have been identified from studies in other diseases associated with alcohol and tobacco consumption. We describe genotype frequencies in 398 oral, pharyngeal and laryngeal squamous cell carcinoma patients and 219 control individuals. Of the genotypes presumed to be protective, only GSTM1 A/B influenced susceptibility; the GSTM1 A/B frequency was lower in the patients than the control individuals both before [odds ratio = 0.3, 95% confidence interval (CI) 0.1-0.7] and after correction for imbalances in age, sex, smoking and alcohol consumption (odds ratio = 0.2, 95% CI 0.1-0.5). Of the putatively risk genotypes, GSTM3 AA, previously associated with susceptibility to skin cancer, was higher in the cases (odds ratio = 1.6, 95% CI 1.1-2.4). Dividing cases into oral/pharyngeal and laryngeal squamous cell carcinoma showed the GSTM3 AA frequency was higher in laryngeal squamous cell carcinoma than control individuals (odds ratio = 1.6, 95% CI 1.1-2.5) and the difference between control individuals and oral/pharyngeal squamous cell carcinoma approached significance (odds ratio = 1.7, 95% CI 1.0-2.8). The putatively protective GSTM3 BB genotype was lower in patients with glottic (1.0%) than supraglottic (3.0%) squamous cell carcinoma. We identified no differences between patients and control individuals in the frequencies of presumed risk genotypes (e.g. CYP2D6 EM, CYP1A1 m1/m1, CYP1A1 Ile/Ile, CYP2E1 DD, CYP2E1 c1c1, GSTT1 null) or, interactions between genotypes and smoking or alcohol consumption. We conclude, first, that mu class glutathione S-transferase influence risk of upper aerodigestive tract cancers thereby complementing studies in skin cancer patients showing GSTM1 A/B is protective, while GSTM3 AA moderately increases risk. The influence of GSTM1 A/B, but not GSTM1 A or GSTM1 B (mostly heterozygotes with GSTM1*0) suggests that two expressed alleles may attenuate risk. While we found immunohistochemical evidence of GSTM3 expression in the cilia lining the larynx, the biochemical consequences of the polymorphism are unclear. Indeed, the influence of the gene may reflect linkage disequilibrium with another gene. However, we did not find an association with GSTM1 genotypes. Second, we conclude that the CYP2D6, CYP2E1, CYP1A1 and GSTT1 alleles studied, although putatively good candidates, either do not determine the effectiveness of detoxification of tobacco-derived carcinogens in the upper aerodigestive tract or, that chronic consumption of tobacco and alcohol overwhelms enzyme defences, irrespective of genotype.

The impact of nucleolar organizer regions for the lymph node spread and prognosis of invasive ductal mammary carcinoma.

In primary tumours of 40 patients with invasive ductal carcinomas the significance of nucleolar organizer regions (NORs) for metastatic spread to the axillary lymph nodes and for the prognosis was assessed. Silver-stained tissue sections were investigated by means of semiautomated image analysis. The nucleolar organizer regions of 100 tumour cell nuclei per specimen were measured. The number as well as the area of the NORs were evaluated together with morphometrical and DNA features, histopathological and clinical data. By means of multivariate discriminant analysis, significant differences between tumours of 20 node-negative and 20 node-positive patients could be found. The mean number of NORs was significantly higher in patients with lymph node metastases (p = 0.0059), whereas the mean area was significantly lower in node-positive patients. By using the NOR number as the only parameter both groups were classified with an overall efficiency of 95%. There was also a significant difference between long-term and short-term survivors by considering the mean number of NORs, but the Auer-type, the 2 cDl value, and the DNA-grade of malignancy were of better predictive value. Within the group of node-negative patients the NOR number was most suitable for distinguishing between good and poor prognosis, whereas within the group of node-positive patients once more the DNA parameters played the most decisive role for predicting prognosis. With regard to the small number of patients the results have to be considered as preliminary. Further investigations in a more extensive population are necessary.

Association of 8p23 deletions with poor survival in head and neck cancer.

OBJECTIVE: Allelic loss at 8p23 occurs frequently in head and neck squamous cell carcinoma. The objective of this study was to determine the prognostic importance of 8p23 loss. STUDY DESIGN AND SETTINGS: We tested 51 primary tumors and 19 lymph node metastases for loss of heterozygosity with 7 microsatellite polymorphisms at 8p23 and correlated the results with disease-free interval and disease-specific survival. RESULTS: The Kaplan-Meier analysis demonstrated statistically significant association of 8p23 allelic loss with both shorter disease-free interval and disease-specific survival. For the pN stage, the log-rank test indicated significance in correlation with the disease-free interval, whereas the pT stage showed a significant correlation with disease-specific survival. Multivariate analysis identified loss of heterozygosity at 8p23 as independent prognostic marker for disease-free interval. CONCLUSION: Our data suggest that 8p23 allelic loss is associated with poor prognosis in head and neck squamous cell carcinoma and could be useful refining diagnosis of these tumors.

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

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

Predictors of the outcome of nasal surgery in terms of olfactory function.

Nasal surgery is frequently performed. Predictors of surgical outcome in terms of chemosensory function are not clear. A total of 64 patients were included in this prospective study (41 men, 23 women; age range 22-67 years). Prior to surgery, patients received a detailed otorhinolaryngological examination including nasal endoscopy, and CT scans used to establish the Lund-Mackay score. Olfactory function was analyzed using a custom-built odor identification test which allowed separation of chemosensory function into "olfactory" and "trigeminal" portions. Retest was performed 6 months after surgery. In terms of the sense of smell, nasal surgery produced the highest success rates in women, high degree of polyposis, and aspirin-intolerance. Neither age, presence of asthma, nor the number of preoperative surgical interventions had a significant impact on the outcome of surgery in terms of chemosensory function. Although "trigeminal scores" changed to a lesser degree than "olfactory scores", the present results indicated that nasal surgery may also improve trigeminal function, although this needs further corroboration. Improvement of olfactory function following nasal surgery appears to last, on average, for at least 6 months. While the present results may be seen as an encouraging step towards the description of more detailed prognostic factors related to nasal surgery, results from the present investigation also point towards the idea that nasal polyposis is due to a multifactorial process that, so far, is not adequately addressed by current research. Future work is needed to identify further predictors of postoperative outcome in terms of olfactory function.

[Modern anesthesiologic concepts supporting paranasal sinus surgery]. / Moderne Anästhesieverfahren in der endonasalen Nasennebenhöhlenchirurgie.

BACKGROUND: Optimal vision is essential for successful endonasal sinus surgery. Beside topical vasoconstriction general anaesthesia can contribute to reduce intraoperative bleeding. METHODS AND RESULTS: For many years deliberate hypotension was used to prevent intraoperative bleeding. The intentional reduction of systolic blood pressure to 50-60 mm Hg was achieved by the use of Sodium Nitroprusside alone or in combination with other vasoactive agents. However, intraoperative bleeding is not affected by this technique unless the systolic blood pressure falls below 60 mm Hg which can cause serious side effects for the patient. Recently, there is growing evidence that not only systolic blood pressure but also a low heart rate (< 60 beats per minute) can minimize surgical bleeding. With the introduction of total intravenous anaesthesia (TIVA) by the use of Propofol and Remifentanyl an anaesthetic technique has been established which fulfils the haemodynamic requirements in endonasal sinus surgery in many regards. The inhibiting effects on the cardiovascular system of these drugs alone can lead to a reduced bleeding. TIVA allows the reduction of the systolic blood pressure to 60 mm Hg as well as the heart rate below 60 beats per minute. If necessary it can be supported by vasoactive agents of which betablockers have a theoretical advantage. CONCLUSION: For general anaesthesia in endonasal sinus surgery Sodium Nitroprusside is no longer recommended. Instead a TIVA using Propofol and Remifentanil should be used.

[Extraosseous osteosarcoma of the thyroid gland]. / Extraossäres Osteosarkom der Schilddrüse.

Extraosseous osteosarcomas are very rare malignant neoplasms that have been published in 300 cases so far. Manifestation within the thyroid gland was described in 6 cases only. We report a 69 year old female who suffered from enlarged recurrent struma after primary resection and radiotherapy 5 years ago. Histology revealed a high grade extraosseous osteosarcoma. Presenting the patient's clinical, radiological and histological findings the therapeutical options of this rare tumor entity are discussed.

[Glottic laryngeal carcinoma. Tis, T1 and T2--long term results after laser resection]. / Glottische Larynxkarzinome. Tis, T1 und T2--Langzeitergebnisse nach Laserresektion.

BACKGROUND: Endoscopic laser resection is one treatment modality for early glottic carcinoma. Benefits are the preservation of laryngeal structure without tracheotomy, the short duration of treatment, low traumatisation and good functional results. METHODS: From 1989 to 1999, 143 patients with an isolated and previously untreated glottic squamous cell carcinoma were treated by CO2 endoscopic laser resection. The tumors were classified as carcinoma in situ (Tis) in seven cases, T1 tumor (T1N0M0) in 91 patients and T2 tumor (T2N0M0) in 45 cases. Median follow-up was 5 years. RESULTS: For the group of Tis and T1 carcinomas, 86 of 98 patients were free of recurrences. The 12 recurrences (12.2%) were treated by repeated laser surgery and laryngectomy (four patients). None of these patients died of tumor related causes. For patients with T2 carcinomas, the overall recurrence rate was 28.9% (13 patients). In six patients, a total laryngectomy had to be performed and one patient died because of tumor recurrence. The relapse free survival estimate using the Kaplan-Meier method was 87% for Tis and T1 carcinomas and 70% for T2 carcinomas. The overall laryngeal preservation rate was 95% for Tis and T1 carcinomas and 85% for T2 tumors. All recurrences occurred within 4 years of primary surgery. CONCLUSION: The results suggest that the oncological outcome after endoscopic laser surgery is comparable to conventional open partial resections.

[Endonasal micro-endoscopic resection of sinonasal inverted papilloma]. / Endonasale mikro-endoskopische Resektion invertierter Papillome der Nase und ihrer Nebenhöhlen.

BACKGROUND: The goal of this study was to assess the potentials and limitations of endonasal micro-endoscopic surgery in the treatment of sinonasal inverted papilloma (IP) and to demonstrate long-term results. PATIENTS AND METHODS: From 1989 to 2005, 64 patients underwent resection of IP via an endonasal approach using either the endoscope or microscope. Charts were reviewed retrospectively for presenting symptoms, radiological and intraoperative data. All patients were followed by endoscopic and MRI control during a period of up to 174 months, median follow-up was 78 months. RESULTS: Our study group consisted of 26 male and 38 female patients with an average age of 54.3 years. The majority of the patients (67 %) complained of unilateral nasal obstruction. 52 patients (81 %) were referred for primary surgery. In 12 cases (19 %) recurrent tumors were operated. According to the Krouse classification for IP the tumors were staged as T1 = 11 (17 %) cases, T2 = 37 (58 %) and T3 = 14 (22 %). In two patients a squamous cell carcinoma was associated with an IP ( = T4 stage). Most tumors were localized within the nasal cavity (72 %) or the anterior ethmoid (62 %). In 10 patients an infiltration of the bony skull base was present. During the follow-up period 6 patients developed recurrencies corresponding to an overall recurrence rate of 9.4 %. CONCLUSIONS: The advances in endonasal micro-endoscopic surgery allow both safe and effective removal of IP with low morbidity, and therefore it should be the approach of the first choice. The osteoplastic approach combined with endonasal surgery is suitable in far lateral located IP. Close follow-up is mandatory to ensure the surgical success.

[Paraganglioma of the head and neck--tumor control, functional results and quality of life]. / Paragangliome des Kopf-Hals-Bereiches--Tumorkontrolle, funktionelle Ergebnisse und Lebensqualität nach Operation.

BACKGROUND: Surgical therapy for paragangliomas (PG) of the head and neck is, due to the alternatives of radiation therapy and wait-and-scan strategy and because of postoperative morbidity, under ongoing discussion. MATERIAL AND METHODS: Between 1981 and 2004, 79 patients with 94 PG of the head and neck were treated at our department. These patients had follow-up examination within a clinical trial considering tumor control, functional results and for the first time neuropsychologically evaluated postoperative quality of life. Mean follow-up time was 65 months (1 to 228 months). RESULTS: Among the 94 PG there were 19 carotid body (GCP), 12 vagal nerve (GVP) and 63 jugular-tympanal paragangliomas (JTP). Of these, 87 tumors underwent surgery. In 68 patients (78.1 %), the tumor could be removed completely. In particular, complete resection of GCP was achieved in 100 %, of GVP in 90.9 %, of JTP type A in 100 %, of JTP type B in 83.3 %, of JTP type C in 66.6 % and of JTP type D in 61.5 %. During the follow-up period, residual or recurrent tumors were diagnosed in 17 patients (19.5 %). Six of the seven residual PG were observed by magnetic resonance tomography and did not show growth. One residual PG and 6 recurrencies were resected completely. One recurrent tumor was radiated and 3 others are under observation without showing growth tendencies. Two patients died postoperatively due to borderline operations of extended tumors. The quality of life after PG surgery showed a SIP of 4.8, which is comparably much better than after acoustic neuroma surgery (SIP 10.3). CONCLUSION: Whereas complete tumor resection of GCP and JTP types A and B is almost ever possible without cranial nerve palsies, surgery of GVP and advanced JTP causes often severe functional deficits. However, postoperative quality of life is mostly good. Nevertheless, advanced PG require an individualized therapeutic regime also including radiation and observation of tumor growth.

[Reconstruction of the frontoorbital frame using split-thickness calvarial bone grafts]. / Tabula externa zur Rekonstruktion des frontoorbitalen Knochengerüstes.

BACKGROUND: There are many autogenous and allogenous grafts as well as alloplastic materials available for the reconstruction of craniofacial bony frame. We review our techniques and describe the advantages of using calvarial bone, especially split-thickness grafts for bone reconstruction in this area. PATIENTS AND METHODS: Between 1996 and 2003 the orbitocranial bony frames of 15 patients were reconstructed using split calvarial bone grafts at the ENT-Department of the Hospital Fulda gAG. In 12 patients the anterior frontal sinus wall or the entire Os frontale were affected. In 1 patient each the lateral wall, roof and floor of the orbit had to be reconstructed. The causes of the bone defects were trauma (n = 6), recurrent frontal sinusitis partly with osteomyelitis (n = 4), benigne tumors (n = 2) and malignancies (n = 3). Twelve patients have had multiple previous operations. In 3 patients the bone reconstruction was performed in the same operation as the tumor removal. Within the follow-up period between 2 and 8 years the split calvarial bone grafts remained stable in size and shape. Graft rejection, osteomyelitis or bone resorption did not occur. Furthermore, we have not experienced significant complications in harvesting cranial bone and have not seen major donor site morbidity. CONCLUSIONS: Our results demonstrate that split-thickness calvarial bone is an excellent graft not only for facial and forehead contouring but also for orbital and complex craniofacial reconstruction.

[Paranasal sinus mucoceles: surgical management and long term results]. / Mukozelen der Nasennebenhöhlen: Chirurgisches Therapiekonzept und Langzeitergebnisse.

BACKGROUND: The aim of this study was to determine the best surgical approach in the treatment of paranasal sinus mucoceles according to their localization. MATERIAL AND METHODS: A retrospective analysis was carried out in 255 patients with 290 sinus mucoceles who were treated surgically at the ENT-Department of the Hospital Fulda gAG between 1983 and 2001. This series include 125 frontal sinus, 23 frontoethmoid, 41 ethmoid, 72 maxillary sinus and 26 sphenoid mucoceles. The patients' history, presenting symptoms, radiological findings, and surgical management were reviewed. Of them, 185 patients were followed by endoscopic and CT or MRI control during a period of up to 19 years, median follow-up was 12 years. RESULTS: In 168 out of 255 patients (66 %) the mucoceles were arisen due to previous sinus surgery, in 37 cases (14 %) after traumatic lesions, in 5 patients (2 %) due to chronic sinusitis and in 2 cases (<1 %) according to tumors. In 43 cases (17 %) no causes were found. In 78.8 % the previous operation was performed via an external approach, either according to Jansen/Ritter or Caldwell-Luc, contrary to 1.5 % after endonasal surgery. The median period until mucocele appearance was 15 years for maxillary sinus, 13 years for frontoethmoid, 10 years for ethmoid, and 8 years for frontal and sphenoid sinus celes, respectively. 201 mucoceles (69.3 %) have been operated endonasal micro-endoscopically, 18.6 % via the osteoplastic approach, 10 % endoscopically combined with an osteoplastic procedure and only 2 % according to Jansen/Ritter. Thereafter, recurrence of mucoceles was found in 4 patients only ( = 2.2 %; related to the endonasal approach = 1.6 %). CONCLUSION: Frontoethmoidal, ethmoidal, sphenoidal and maxillary sinus mucoceles are excellent indication for exclusively endonasal micro-endoscopic surgery. The osteoplastic approach combined with endonasal surgery is suitable in far lateral located frontal or maxillary sinus mucoceles.

[Management of congenital nasal fistulas and cysts]. / Operatives Management von kongenitalen Nasenfisteln und -zysten.

BACKGROUND: Congenital nasal fistulas and cysts are uncommon craniofacial malformations. Mostly their symptoms appear already during childhood. In general, they are superficially located but they can reach the skull base or extend intracranially. PATIENTS AND METHODS: Between 1979 and 2004 fifteen patients (11 children and 4 adults) with nasal fistulas and cysts were treated surgically at the ENT-Department of the Hospital Fulda gAG. In 7 patients (46.6 %) the skull base was involved. An intracranial intradural extension was found in 1 child and therefore needed a combined ENT and neurosurgical procedure. In the other 6 cases the nasal fistulas or cysts were located extradurally. They were resected by removing the Christa galli and strenghten the dura. An additional septorhinoplasty was carried out in 4 of the 15 patients. Within the follow-up period of up to 25 years no recurrences were observed. CONCLUSIONS: The adequate therapy of nasal fistulas and cysts consists of complete resection. Magnetic resonance tomography (MRI) and computed tomography (CT) are essential to diagnose intracranial extension and to choose the proper surgical approach including a potential interdisciplinary procedure.