[Hebephrenia - a viable psychopathological construct?] / Hebephrenie ­ ein brauchbares psychopathologisches Konstrukt?

Ewald Hecker was the first psychiatrist to describe the disease entity of hebephrenia in some detail, focusing mainly on disturbances of affect. Later Emil Kraepelin and Eugen Bleuler saw hebephrenia as a subtype of dementia praecox or schizophrenia. Willy Mayer-Gross and Karl Leonhard characterized hebephrenia with highly differentiated psychopathological descriptions, whereas this construct only played a minor role in the works of Klaus Conrad and Kurt Schneider. The International Classification of Diseases (ICD-10) lists hebephrenia as a subtype of schizophrenia but in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) no subtypes of schizophrenia are mentioned and the concept of hebephrenia is thus lost. Hebephrenia can be seen as an ideal type describing a psychopathological course pattern. This construct can be useful to conceptualize a group of disorders of affect which otherwise escape description, especially since these psychopathological alterations of affect are difficult to operationalize. To have a viable concept of these disorders is relevant for the prognosis and therapy planning. If the concept of hebephrenia is abolished, important psychopathological knowledge might be lost for future generations of psychiatrists.

[Psychiatry as a practical science : Considerations following Wolfgang Wieland (1933-2015)]. / Psychiatrie als praktische Wissenschaft : Überlegungen nach Wolfgang Wieland (1933­2015).

In the light of historical and modern criticism of the discipline of psychiatry and psychotherapy as a medical subspecialty, this paper deals with aspects of the theory of medicine as postulated by the physician and philosopher Wolfgang Wieland. According to his contributions medicine is a practical science aiming at establishing rational action. Central to this model is a diagnosis, which helps to subsume individual cases under general principles from which essential therapeutic options can be derived. Hence, psychiatry and psychotherapy become a medical subspecialty by adopting the basic model of medical reasoning and action as described by Wieland. Nevertheless, the limits of such an approach must be taken into consideration. Especially in a psychiatric and psychotherapeutic context it is of particular importance that even when being guided by general principles the responsibility for the personality of each individual patient should be adequately met. Furthermore, attention should be paid to the limits of the subspecialty of psychiatry and psychotherapy as a medical discipline, which also requires a critical analysis of the concept of psychiatric illness.

[The Concept of Typology in Psychiatry in the Context of Historical Contributions of Max Weber and Karl Jaspers]. / Das Typuskonzept in der Psychiatrie - Überlegungen nach Max Weber und Karl Jaspers.

Against the background of Max Weber's and Karl Jaspers' outstanding historical contributions to the conceptual development of different typologies, the importance of a psychiatric typology is examined. The term "ideal type" was introduced into social science by Weber as an analytical construct to describe and classify cultural phenomena. This concept was adopted for the psychiatric context by Jaspers who proposed to establish a typological system in the field of psychotic disturbances without an organic correlate. He emphasized the importance of the course of psychopathological symptoms for such a typological system. The concept of typology can be regarded as a promising heuristic approach in psychiatry, providing a classification system for complex psychopathological symptoms. Even though several historic typologies exist in psychopathology, their usefulness in the fields of therapy and prognosis needs to be critically assessed. Also, new typologies will have to be developed, taking into account neurobiological knowledge now available.

Results of endoscopic sinus surgery for the treatment of inverted papillomas.

Fifty-one patients suffering from inverted papillomas of the nose and paranasal sinuses were reexamined in a retrospective study. Thirty-five had undergone surgery by an intranasal endoscopic approach and 16 had undergone surgery by an extranasal approach. The recurrence rate following endoscopic interventions was 17% (6/35), as compared to 19% (3/16) after extranasal operations. Endoscopic surgery proved to be successful even in the treatment of large lesions affecting the posterior ethmoidal sinus, the nasofrontal duct, or the sphenoidal sinus. Its indication thus no longer needs to be restricted to limited lesions of the anterior nasal cavity. Patients with inverted papillomas will benefit from this surgical technique which remains minimally invasive and thus retains the paranasal bony framework, preserves unaffected mucosa capable of recovery, and prevents damage to the patients' cosmetic features.

Enlarged middle fossa vestibular schwannoma surgery: experience with 735 cases.

OBJECTIVE: To show the clinical outcome in patients with sporadic vestibular schwannoma (VS) operated on by the enlarged middle cranial fossa approach (EMFA). STUDY DESIGN: Retrospective case review. SETTING: A tertiary referral center with four neurotologists experienced in EMFA surgery. PATIENTS: There were 376 women and 359 men, with a mean age of 51.1 years (range, 12-77). INTERVENTION: Enlarged middle cranial fossa approach surgery. MAIN OUTCOME MEASURES: Magnetic resonance imaging and computed tomography scans were used for follow-up and re-evaluation of the operative sites. Facial nerve function and hearing were tested. RESULTS: Overall complete VS removal was achieved in 97.1% of patients. There were two recurrences (0.3%) after microscopically complete tumor removal. Depending on the tumor size, postoperative normal and near-normal facial outcome ranged from 83% to 99% (average, 92%), and hearing at or near the preoperative level (+/-15 dB pure-tone average or +/-15% speech discrimination) was preserved in 60.2%, 48.2%, 23.9%, and 17.6%, respectively. CONCLUSIONS: The EMFA is an excellent low-morbidity approach for VS removal with limited cerebellopontine angle extension (2 cm). Specific advantages of the EMFA are the superior internal auditory canal exposure, resulting in an extremely low tumor recurrence rate; best capability for hearing preservation; and minimal incidence of cerebrospinal fluid leaks. Postoperative facial function outcome compares with that of other surgical approaches. The best results are achieved in subjects with small tumors and good hearing, advocating early diagnosis and treatment.

Endonasal endoscopic closure of cerebrospinal fluid fistulas at the anterior cranial base.

This study reports our indications and limits for endonasal endoscopic closure of dural defects with a cerebrospinal fluid (CSF) leak at the anterior cranial base, and demonstrates our surgical technique. Fifty-three patients with CSF rhinorrhea were reassessed for the success rate of closure of the CSF leak. Surgery was successful in 98%, and 68% of fistulas were closed endoscopically. A free graft of autogenous mucoperiosteum of the inferior turbinate was the most frequently used tissue for defect closure. The endonasal endoscopic route proved relatively safe for the closure of dural tears, irrespective of the cause, up to about 10 x 10 mm. It is characterized by minimal morbidity because of the preservation of sinus ventilation and bony structures, supraorbital nerves, and olfactory fibers. Defects larger in size, predominantly of traumatic origin, were closed via the transfacial approach. The decision on the surgical approach was additionally based on the extent of the facial soft tissue injuries and the localization of the leak.

Cranial nerve and hearing function after combined-approach surgery for glomus jugulare tumors.

In this retrospective study, oncologic and functional results of 46 patients treated for glomus jugulare tumor are reported. The standard surgical approach was the combined transmastoid-transcervical approach, modified according to the individual tumor growth, and eventually combined with a transtemporal or a suboccipital approach. Complete tumor removal resulted in a cure rate of 90%. New-onset cranial nerve palsies developed in less than 22% of patients. In 54% of cases it was possible to retain middle ear function. From a total of 12 patients with incomplete tumor removal and postoperative irradiation, progressive tumor growth was noted in 4 patients, and was controlled by salvage irradiation or surgery. Radical tumor removal by ablative surgery can be modified by efforts to reduce multilating resections. In their place, individually tailored and combined multidirectional surgical approaches may allow total tumor removal with lower morbidity.

Nasal airway changes after Le Fort I--impaction and advancement: anatomical and functional findings.

Twenty patients were studied prospectively to assess intranasal anatomical changes and functional changes resulting from a one-piece Le Fort I-osteotomy with anterior and superior positioning of the maxilla. Presurgical and 3 months postsurgical rhinological inspection, anterior rhinomanometry and acoustic rhinometry were performed. Interalar width was measured and cephalograms were used to assess maxillary movement. Rhinoscopically, three septal perforations (15%) were noticed. Turbinate enlargement was less common postoperatively. Interalar width increased significantly. These findings correlate with a significant increase in cross-sectional diameter at the Isthmus nasi revealed by acoustic rhinometry 3 months postoperatively. The mean total nasal airflow measured by anterior rhinomanometry was unchanged indicating no increase in resistance despite decreased intranasal dimensions in cases where the impaction is not higher than 5 mm.

Advantages of the enlarged middle cranial fossa approach in acoustic neurinoma surgery. A review.

Utilizing an enlarged middle cranial fossa approach to the cerebello-pontine angle without destruction of the labyrinth or cochlea the authors have since 1981 operated on 263 unilateral acoustic neurinomas. Tumour sizes ranged between 3 mm intrameatal and 35 mm within the cerebello-pontine angle. Complete tumour removal was accomplished in 96%. There was one postoperative mortality, and only rarely neurological complications. Excellent function of the facial nerve was obtained in 78% (in small and medium sized neurinomas 90% House I and II) and severe paralysis persisted in only 6%. Preservation of hearing was possible in 70% of the small tumours, and in 50% of the total group. Against this background comparable data of the literature are reviewed, and the indications for the enlarged midfossa approach analyzed.

Selective resection of the semicircular canals of rabbits with preservation of hearing.

The goal of this investigation was to develop a method of surgical removal of the semicircular canals of the rabbit without induction of auditory impairment. Four different surgical techniques were utilized: i) fenestration of the lateral semicircular canal; ii) fibrin glue perfusion of the canal following fenestration; iii) removal of the lateral semicircular canal by drilling after fenestration and fibrin glue perfusion, and iv) removal of all three canals after fenestration and fibrin gluing. Brainstem auditory potentials were recorded repeatedly for up to 3 months after operation and demonstrated preservation of hearing in all rabbits in the first group and in 78% of the second group. In the third group the potentials could be recorded in 67% of the animals and showed a 20 dB deterioration of hearing. After removal of all three semicircular canals residual hearing could be recorded in 50% of the rabbits. These animals regularly showed a 30-40 dB deterioration of hearing. A precise microsurgical technique using fibrin glue and bone chips for interruption of the peri- and endolymph flow proved crucial for hearing preservation.

Preservation of hearing in bilateral acoustic neurinomas by deliberate partial resection.

With the aim of preserving hearing, 20 acoustic neurinomas in 17 patients with neurofibromatosis 2 were intentionally submitted to an incomplete (80%) tumour removal. In 12 cases this was an operation on the last hearing ear with total deafness of the contralateral ear. If an auditus existed in both ears the better hearing ear was selected for the primary intervention. Early audiological controls evidenced residual hearing in 19 of the 20 cases operated on by the enlarged middle fossa approach, which was utilized inspite of the tumour diameters being between 1 and 6 cm in the cerebello-pontine angle. The oncologic and functional follow-up over 1 to 7 years showed different patterns of slow progression of hearing loss and of persistent auditory function over 2 to 7 years. Facial nerve function was excellent in 16 of the 18 controlled cases. Continued CT or MRT imaging revealed no signaling in 2 cases, constant tumour sizes in 10 cases and slow progression in 3 cases. With regard to the importance of an auditory communication in the younger adult, the described treatment modality appears to be the first choice method.

Arachidonic acid metabolism in nasal tissue and peripheral blood cells in aspirin intolerant asthmatics.

Aspirin intolerance (AI) is characterized by polypous rhinosinusitis, bronchial asthma and adverse reactions to aspirin. The common intolerance to all cyclo-oxygenase inhibitors allows us to focus study of the pathogenesis of AI on the metabolism of arachidonic acid (AA). We studied the metabolism of AA in nine aspirin intolerant asthmatics (AIA) and eight healthy volunteers (controls) by measuring prostaglandin E2 (PGE2) and peptido-leukotrienes (pLT = LTC4/D4/E4) in nasal tissue and peripheral blood cells (PBCs) using a specific immunoassay. In all patients with AI the tests were performed before and after bronchial provocation with lysine-ASA. In the control group the tests were done before and after 500 mg ASA p.o. The release of pLT in nasal polyps of AIA was found to be significantly higher than in normal mucosa of AIAs and controls. In every tissue a significant increase of pLT after aspirin challenge was observed. Nasal polyps of AIA show a significantly lower release of PGE2 than normal mucosa of AIAs and controls. Peripheral blood cells of AIA show a significantly higher release of pLT and a significantly lower release of PGE2 than PBCs of controls. Therefore clinical manifestations of AI may be based on an alteration of AA metabolism in AIA.

Topographical anatomy of the internal auditory canal. Implications for functional surgery in the cerebello-pontine angle.

For exposure of the cerebello-pontine angle by an enlarged middle-fossa approach without destruction of the inner ear, bone removal anterior and posterior to the internal auditory meatus (c.a.i.) can be performed with orientation at landmarks. Based on the experience of more than 300 interventions and documented by a series of 10 temporal bone micro-dissections, rules have been established for reliable localization of the following structures: geniculate ganglion, Fallopian canal, vertical crest at the fundus of the c.a.i., basal coil of the cochlea, and ampulla of the superior semicircular canal. The surgical technique has enabled the authors to remove acoustic neurinomas of up to 3.5 cm with preservation of hearing in 51%.

Experimental sensorineural hearing loss following drill-induced ossicular chain injury.

In a guinea pig model, a standardized drill-induced injury to the body of the incus was applied, and the effects on hearing were characterized by electrocochleography. Drilling resulted in a threshold shift within seconds, and after 15 min it averaged 35.7 dB for clicks, 35 dB nHL for 4 kHz bursts, 36.7 dB nHL for 6 kHz bursts and 39 dB nHL for 8 kHz bursts. The deterioration of the threshold shift remained stable throughout the 5-week post-operative observation period. In five animals a disarticulation of the incudostapedial joint was performed prior to drilling, but this did not reduce the threshold shift. Caution is mandatory during drilling around an intact ossicular chain to avoid a permanent sensorineural hearing loss, and disarticulation of the incudostapedial joint prior to drilling has no protective value.

Transnasal ethmoidectomy under endoscopical control.

Endonasal sinus surgery aims at the preservation of a lining mucosa in the reventilated and redrained cavities. It can, therefore, be confined to the removal of narrowing bone at the "isthmus" of the ducts or windows. Transnasal ethmoidectomy for diffuse polyposis consists of the removal of the ethmoidal cell septa, including the middle turbinate, and a broad fenestration of both the sphenoid sinus and the frontal infundibulum. A consequent postoperative care provided, transnasal ethmoidectomy offers excellent clinical results. A new suction-irrigation endoscope and refined instruments contribute to improved surgical exposure and to the avoidance of complications.

[Enlarged middle fossa approach to the cerebello-pontine angle. Technique and indications]. / Voie d'abord sus-pétreuse élargie à l'angle ponto-cérébelleux. La technique et les indications.

Our enlarged middle fossa approach, first published in 1982, aims to expose the internal auditory meatus and cerebello-pontine angle from above, with preservation of the cochlea and labyrinth. The steps of the operation are described, especially certain technical details: the skin incision, resection of the squamous temporal bone, extradural exposure of the petrous temporal bone, subsequent resection of the middle meningeal artery and superior petrosal sinus, extensive bone removal behind and in front of the internal auditory meatus, opening of the dura mater to expose the brain stem, and plastic closure of the defects. Believing in the advantages of this approach, we have modified the technique for various indications, including decompression of the facial and cochleovestibular nerves for cases of vascular compression and Menière's disease; management of temporal bone fractures with CSF leak of facial nerve damage; extensive cholesteatoma of the petrous bone; meningiomas or other tumours of the petrous bone; neuromas of the facial or vestibular nerve. It should be emphasised that the middle fossa approach may be combined with other approaches in the resection of lateral skull base tumours with preservation of the inner and middle ear.