[Contemporary use of instruments during clinical examination in German ENT departments and private practices]. / Einsatz von Instrumenten bei der klinischen Untersuchung in deutschen HNO-Abteilungen und Privatpraxen heutzutage.

BACKGROUND: The classical forehead reflector as traditionally used by ear, nose, and throat (ENT) physicians for the ENT examination is now iconic for doctors in general. It is unknown which instruments are currently used in Germany to clinically examine ENT patients. Therefore, this study aims to present results of a survey about commonly used instruments. MATERIALS AND METHODS: An evaluation of 321 questionnaires from ENT doctors working in general and university hospitals (172) and in private practices (149) was performed. RESULTS: The ENT mirror examination is nowadays carried out with a self-illuminating headlamp with battery and/or light guide cable. Approximately 20% of respondents also use a forehead mirror. The microscope is used by 90% of doctors to examine the ears; a rigid endoscope was used in 53.3% to examine the larynx, epipharynx (41.1%), and the nose/sinuses (34.6%). Flexible endoscopes and otoscopes are used only rarely. CONCLUSION: The self-illuminating headlamp, which is more often wireless in eastern Germany, has largely replaced the classical forehead reflector, with which doctors younger than 40 years were no longer trained. At least some organs are also examined very regularly with the microscope or rigid endoscope. The flexible endoscope and otoscope are used much less frequently overall, mainly by younger physicians and ENT doctors working in hospitals. The diagnostic potential of flexible endoscopy may be compromised by the outpatient remuneration structures in Germany.

[Second opinion process for tonsillectomy and tonsillotomy: analysis of the quantitative and qualitative justifying conditions]. / Zweitmeinungsverfahren für die Tonsillektomie und Tonsillotomie: eine Analyse der rechtfertigenden quantitativen und qualitativen Voraussetzungen.

BACKGROUND: In 2017, the Federal Joint Committee determined tonsillectomy and hysterectomy in non-oncologic diseases as well as tonsillotomy for second opinion procedure. We discuss the suitability of tonsillectomy and tonsillotomy for the second opinion procedure on its quantitative and qualitative characteristics. MATERIALS AND METHODS: Data from the Federal Statistical Office concerning numbers of cases were evaluated. Numbers and regional distribution of ENT-specialists providing second opinion were analyzed by websites of Associations of SHI Physicians. RESULTS: Between 2005 and 2018a significant decrease in tonsillectomy cases from 119 808 to 42 548 is observable that is by far not compensated by increasing tonsillotomy numbers from 4659 (2007) to 18 369. At the same time, surgical procedure rates at regional levels remain volatile. 218 ENT-specialists in 142 towns provide second opinion. On basic of case numbers in 2018a relationship of 1(ENT-specialist): 280 (tonsillectomy/tonsillotomy patients) results (range from 1:90 to 1:800). CONCLUSIONS: On the background of decreasing surgical rates tonsil surgery does not comply with the requirements of second opinion procedure. Reachability of second opinion providers is difficult in many regions, such compromising a compensation of different levels of surgery. As a result of our investigation we recommend scientific supervision of currently second opinion procedures and a survey of actual demand from the patient's viewpoint.

Increased incidence of Warthin tumours of the parotid gland: a 42-year evaluation.

AIM: To evaluate the frequency of Warthin tumours among parotid neoplasms over the past 42 years in a population in rural Germany and to identify potential risk factors. METHODS: We conducted a retrospective case note evaluation from all patients who underwent parotid surgery between 1975 and 2017. The 42-year time period was evenly split into four quartiles. RESULTS: A Warthin tumour was diagnosed in 265 out of 806 patients (32.9%). The frequency of Warthin tumour increased steadily from 20.6% in the first decade between 1975 and 1986 to 44.9% in the fourth decade between 2008 and 2017. The age of the patients decreased from 68 years in the first to 62 years in the fourth decade. The male-to-female ratio in Warthin tumour was reduced from 1:5.3 in the first to 1:2.1 in the fourth decade. CONCLUSION: A Warthin tumour was the most common histological tumour type in the period from 1997 to 2017. We also found a high incidence of multiple tumours, a growing incidence in women and a decreasing age of patients. We propose a re-evaluation of the existing view of the epidemiology of benign parotid tumours, which proposes that pleomorphic adenoma is the most common benign parotid tumour.

Correction to: Increased incidence of Warthin tumours of the parotid gland: a 42-year evaluation.

In the original publication, in Table 2, the last value of third column, referring to `Number of cases' has been misprint. It should read "265" instead of the "235". The corrected table 2 is given below.

[Altered indication for parotidectomy in north-western Brandenburg: A longitudinal study]. / Veränderte Indikation zur Parotidektomie im nordwestlichen Brandenburg: Eine Longitudinaluntersuchung.

OBJECTIVE: Knowledge about parotoidectomy indications is based on notifications to ENT departments and tumor databases. The study investigates the hypothesis that the surgical indication for parotoidectomy has changed over recent years. MATERIAL AND METHODS: We performed a retrospective observation study of patients who underwent parotidectomy between 1975 and 2016 (subdivided into 4 quartiles) in a teaching hospital of a medical university. RESULTS: 405 men and 366 women underwent operation for benign tumors (600/78 %), malignant tumors (116/15 %) or parotitis (55/7 %). The proportion of benign tumors remained unchanged (78 %), whereas malignant tumors increased (7 % - 23 %) and parotitides decreased (17 % - < 1 %). In benign tumors, the proportion of pleomorphic adenomas decreased (60 % - 24 %), whereas Warthin tumors increased (23 % - 58 %). Among malignant tumors, the proportion of metastases increased from 2/13 to 31/49 (in particular squamous cell carcinomas of the skin). CONCLUSIONS: The present the study shows the decreasing importance of parotitis as an indication for parotidectomy due to improved non-surgical procedures. The increasing prevalence of Warthin tumors was associated with an increasing proportion of smokers. Increased number of malignant tumors was caused by an increased prevalence of intraparotidial matastases of cutaneous squamous cell carcinoma. The presented results are based on the evaluation of patient charts. Due to their ICD or DRG reference, histological findings cannot be generated by evaluating databases. For this purpose, a special salivary gland tumor database should be established.

Diagnostic relevance of metastatic renal cell carcinoma in the head and neck: An evaluation of 22 cases in 671 patients.

PURPOSE: Renal cell carcinoma (RCC) is a malignant tumor that metastasizes early, and patients often present with metastatic disease at the time of diagnosis. The aim of our evaluation was to assess the diagnostic and differential diagnostic relevance of metastatic renal cell carcinoma (RCC) with particular emphasis on head and neck manifestations in a large patient series. PATIENTS AND METHODS: We retrospectively evaluated 671 consecutive patients with RCC who were treated in our urology practice between 2000 and 2013. RESULTS: Twenty-four months after diagnosis, 200/671 (30%) of RCC had metastasized. Distant metastases were found in 172 cases, with 22 metastases (3.3%) in the head and neck. Cervical and cranial metastases were located in the lymph nodes (n=13) and in the parotid and the thyroid gland, tongue, the forehead skin, skull, and paranasal sinuses (n=9). All head and neck metastases were treated by surgical excision, with 14 patients receiving adjuvant radiotherapy and 9 patients receiving chemotherapy or targeted therapy at some point during the course of the disease. Five patients (23%) survived. The mean time of survival from diagnosis of a head and neck metastasis was 38 months, the shortest period of observation being 12 months and the longest 83 months. DISCUSSION AND CONCLUSION: Our findings show that while RCC metastases are rarely found in the neck, their proportion among distantly metastasized RCC amounts to 13%. Therefore, the neck should be included in staging investigations for RCC with distant metastases, and surgical management of neck disease considered in case of resectable metastatic disease. Similarly, in patients presenting with a neck mass with no corresponding tumor of the head and neck, a primary tumor below the clavicle should be considered and the appropriate staging investigations initiated.

Re-irradiation for head and neck cancer: outcome and toxicity analysis using a prospective single institution database.

Purpose: Re-irradiation (re-RT) in head and neck cancer is challenging. This study prospectively explored the feasibility of re-RT in patients with loco-regionally recurrent or second primary head and neck cancer (LRR/SP HNC). Methods: From 2004 to 2021, 61 LRR/SP HNC patients were treated with re-RT, defined as having a second course of RT with curative intent resulting in a cumulative dose of ≥100 Gy in an overlapping volume. Postoperative or definitive dynamic intensity-modulated and/or volumetric modulated re-RT was administered using twice daily hyperfractionation to 60 Gy combined with cisplatin or carboplatin/5-fluorouracil. Overall survival (OS), progression-free survival (PFS), locoregional control (LRC) and distant metastasis control (DMC) were analyzed and prognostic factors evaluated. Toxicity was prospectively recorded and graded. Results: The median follow-up was 9.8 months. In 41 patients (67.1%), complete administration of the intended treatment was not feasible. In 9 patients (15%) re-RT was interrupted prematurely and in other 9, the complete re-RT dose was lower than 60 Gy, and 37 patients (61%) could not receive or complete chemotherapy. Two-year OS, PFS and LRC rates were 19%, 18% and 30%, respectively. 20 patients (33%) received the complete intended treatment, and 1- and 2-year OS rates were 70% and 47%, respectively. Charlson comorbidity index was an important predictor for treatment completion. Multivariate analysis revealed recurrent N stage 0-1, age, chemotherapy administration and re-RT dose of 60 Gy as prognostic factors for clinical outcomes. No grade 5 re-RT-related toxicity was observed. The most common new grade ≥3 acute toxicities were dysphagia (52%) and mucositis (46%). Late toxicity included grade ≥3 dysphagia in 5% and osteoradionecrosis in 10% of evaluable patients, respectively. 6 patients (10%) were alive after 9 years without progression and no late toxicity grade ≥3, except for 2 patients presenting with osteoradionecrosis. Conclusion: Hyperfractionated re-RT with 60 Gy combined with platinum-based chemotherapy was a curative treatment option with acceptable toxicity in LRR/SP patients. Patients with higher comorbidity had a higher probability of failing to receive and complete the intended therapy. Consequently, they derived unsatisfactory benefits from re-RT, highlighting the importance of patient selection.

Tonsillectomy as a Prevention Strategy in the Light of Increasing Incidence of Oropharyngeal Cancer - a Research of Current Literature.

BACKGROUND/AIM: While in many Western countries the number of tonsillectomies decreases significantly, there is an increasing incidence of oropharyngeal carcinomas. For, obviously, removal of the tonsils will reduce individual risk for tonsil cancer, the question of tonsillectomy as a prevention strategy is suggested. This study focused on this question by carrying out a literature research. MATERIALS AND METHODS: A literature research was performed (www.pubmed.gov; Search words: tonsillectomy, oropharyngeal cancer, tonsil cancer, prevention) without applying additional filters. RESULTS: Out of the 16 identified studies, three population-based studies were evaluated. Individual incidence of tonsil cancer is significantly lower after removal of tonsils; however, risk elimination by tonsillectomy has not been proven. One of the studies revealed increasing numbers of base of the tongue cancer after previous tonsillectomy. CONCLUSION: The increase in oropharynx carcinomas can currently be attributed not to the decreasing tonsillectomy rates, but to the increase in HPV infections. A previous tonsillectomy reduces the individual risk of developing tonsil carcer. Tonsillectomy as prevention for oropharyngeal cancer cannot be recommended and may even be a disadvantage concerning base of the tongue cancers.

Second opinion programmes in Germany: a mixed-methods study protocol.

INTRODUCTION: Second opinion programmes aim to support the patients' decision-making process and to avoid treatments that are unnecessary from a medical perspective. The German second opinion directive, introduced in December 2018, constitutes a new legal framework in statutory health insurance for seeking second opinions for elective procedures and so far includes tonsillectomy, tonsillotomy, hysterectomy and shoulder arthroscopy. The directive mandates physicians who recommend one of the above-mentioned surgeries to inform their patients of their legal right to visit a certified second opinion provider. Since second opinion programmes are a fairly recent phenomenon in Germany, no comprehensive data are yet available on the degree of implementation, users, potential barriers and their effectiveness. We aim to examine the characteristics and the use of second opinion programmes as well as the needs and wishes from the perspective of (potential) users in Germany, with focus on the decision-making process, the patient-physician relationship and the motivation to seek a second opinion, as well as the role of health literacy. METHODS AND ANALYSIS: Six substudies will include the following stakeholders: (1 and 2) patients with one of the four surgery-indications covered by the directive, (3) patients who electively sought an online-based second opinion, (4) patients with oncological diseases, (5) the general population and (6) medical specialists. A mixed-methods approach will be used, including questionnaires, interviews and focus groups. The data will be evaluated using quantitative descriptive analysis and qualitative content analysis. The integration of the results will take place in the form of a triangulation protocol. ETHICS AND DISSEMINATION: The study protocol was approved by the Ethics Committee of the Brandenburg Medical School. The findings will be published in peer-reviewed journals and presented at scientific conferences.

The Heterogenicity of Parotid Gland Squamous Cell Carcinoma: A Study of 49 Patients.

BACKGROUND/AIM: The aim of this study was to critically evaluate diagnostic workup, treatment and outcome of parotid gland squamous cell carcinoma (SCC). PATIENTS AND METHODS: We retrospectively examined 844 consecutive cases of parotid surgery in a German teaching hospital between 1975 and 2017. RESULTS: A total of 748 patients had parotid surgery. A total of 118 patients (15.7%) had a malignant tumour. Of those 49 patients had SCC accounting for 6.6% of all cases, and 41.5% of all malignant tumours. SCC typically affected males (79.6%) of advanced age. A total of 86% of patients had metastatic disease; three cases were primary SCC. Most primary carcinomas were skin (n=26) or pharynx (n=10). Four cases were carcinomas of unknown primary. We performed radical parotidectomy in 47 cases, neck dissections in 42 cases and adjuvant chemo-radiotherapy in 44 cases. CONCLUSION: The majority of parotid SCC are metastases. In cases without known primary lesion and lack of infiltrative tumour growth, a carcinoma with unknown primary should be considered.

Cystic Lateral Neck Lesions: Etiologic and Differential Diagnostic Significance in a Series of 133 Patients.

BACKGROUND: Patients presenting with a cystic lateral neck lesion may present diagnostic challenges against a backdrop of varied non-malignant and malignant etiologies. PATIENTS: A total of 133 consecutive cases who underwent cystic neck tumor removal were evaluated for etiology and diagnostic procedure in order to develop an algorithm for therapeutic efficiency. RESULTS: In 92 of 133 cases, a non-malignant tumor was diagnosed. In 41 cases, malignant lymphadenopathy was found. In cases with malignancy, males (p=0.001) and the elderly (p=0.001) were affected more frequently. Primary tumors were discovered by pan-endoscopy before neck surgery or in a second pan-endoscopy (with tonsillectomy and mapping biopsies) in cases with histologically confirmed squamous cell carcinoma. During intraoperative frozen-section evaluation (40 cases), a total of 30 patients underwent neck dissection during the first neck operation. CONCLUSION: In patients older than 40 years who present with cystic neck lesions, we recommend pan-endoscopy and intraoperative frozen section in cases where malignancy is suspected in order to avoid secondary neck dissections and delays in therapy.

Sialendoscopy plus laser lithotripsy in sialolithiasis of the submandibular gland in 64 patients: A simple and safe procedure.

OBJECTIVE: To demonstrate the safety and efficiency of holmium laser-assisted lithotripsy during sialendoscopy of the submandibular gland using a retrospective, interventional consecutive case series. METHODS: We performed 374 sialendoscopies between 2008 and 2015 and evaluated all patients regarding clinical symptoms, clinical findings, therapy and outcome. We performed 109 procedures of holmium laser-assisted lithotripsy in 64 patients whose sialoliths measured 5 mm or more in diameter. In addition to retrospective case note reviews, we performed telephone interviews of all patients in January 2017. RESULTS: We performed 374 consecutive submandibular gland sialendoscopy procedures in 276 patients between 2008 to 2015. Sialolithiasis had either previously been diagnosed, or symptoms highly suggestive of sialolithiasis of the submandibular gland presented in 197 patients. Holmium laser-assisted Laser lithotripsy was performed in 109 cases (64.9%). Smaller mobile concrement was removed directly either by forceps or wire basket, or following marsupialisation of the submandibular duct. This was the case in 88 patients (29.1%). Three patients (0.8%) required surgical removal of the submandibular gland due to early abscess. The majority of patients (n = 374 procedures; 90.1%) remained symptom-free after two or more years following intervention. In the remaining procedures (n = 37 procedures; 9.9%), patients reported discreet postprandial problems but did not seek medical attention. In total, we managed to preserve the submandibular gland and avoid open surgery in 99% of patients through endoscopic management of submandibular concrement and duct stenosis. CONCLUSION: Holmium laser-assisted lithotripsy is a simple, safe, and effective procedure for treating patients with sialolithiasis of the submandibular gland. Removal of the gland is rarely required, and removing the gland without prior sialendoscopy is no longer recommended. It should be offered to all patients with submandibular gland sialolithiasis, or such patients should be referred to the appropriate centre for sialendoscopy before submandibulectomy is considered.

Etiologic and differential diagnostic significance of tumor location in the supraclavicular fossa.

OBJECTIVE: Patients presenting with a cervical mass are common for head and neck specialists and present a diagnostic challenge against the backdrop of a wide variety of etiologies. The objective of the present study was to evaluate the significance of a mass in the supraclavicular fossa for etiology, diagnostic procedure, and therapy. STUDY DESIGN: Individual retrospective cohort study. METHODS: We reviewed the data of 211 consecutive cases (116 male, 95 female) with excisional biopsy or tumor removal of a supraclavicular mass. RESULTS: In 202 of 211 cases, a biopsy was taken from a lymph node. In 182 biopsies, a malignant lymphadenopathy was found (117 metastases, 65 malignant lymphoma). The histologic findings of metastatic diseases were adenocarcinoma (48), followed by squamous cell carcinoma (22). The majority of primary carcinomas were located below the clavicle (94), in the lung (32), in the breast (29), and in the head and neck region (18). In the left supraclavicular fossa, only metastases of the genitourinary tract were significantly more frequent (16 of 17). In nonmalignant tumors (29), tuberculosis (11) was most prevalent. In 79% of biopsies, the neck mass was the first manifestation of the disease. CONCLUSION: The location of a cervical mass in the supraclavicular fossa provides a strong indication of malignancy. A biopsy is mandatory in the majority of patients presenting with a supraclavicular mass. In cases of metastatic disease, the location of a cervical mass helps identify the primary site. Histologic findings are essential for further diagnostic steps, therapy, and prognosis. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:646-650, 2018.

Metastases to Both Parotid Glands Six and Twelve Years after Resection of Renal Cell Carcinoma.

Metastases of renal cell carcinoma (RCC) involving the parotid gland are very rare. We present to our knowledge the first case of a 74-year-old woman with metastases of an RCC which affected both parotid glands six and twelve years following curative therapy.

Are Multiple Tumors of the Parotid Gland Uncommon or Underestimated?

BACKGROUND/AIM: Parotid gland tumors are mostly solitary tumors of the salivary gland tissue. There is limited evidence about multifocal tumor growth of the parotid gland. PATIENTS AND METHODS: We reviewed medical records of 796 consecutive parotidectomies in 758 patients over the last 40 years in our department, and investigated the incidence and histological type of synchronous and metachronous parotid tumors. Multifocal recurrent tumors and hybrid tumors were excluded. RESULTS: We identified 93 (13%) patients with multiple parotid lesions. Their mean age was 63 (range=15-93) years. Multiple parotid tumors were found unilaterally in 59% and bilaterally in 41% of cases. The contralateral tumor was diagnosed synchronously in 13 of 38 (34%) cases and in 25 of 38 (66%) cases metachronously. The time separating the diagnoses of both contralateral tumors ranged between one and eleven years. The same histological type was found in 95% of the tumors, and 96% of the parotid tumors had lymphatic origin. Warthin tumors (65%) were the most frequent histological type. CONCLUSION: Every sixth patient with a parotid tumor has multifocal tumor lesions. The majority of multifocal parotid tumors have a lymphoid element, while multifocal growth is uncommon in other histological types.

Parotid gland metastases of distant primary tumours: A diagnostic challenge.

OBJECTIVE: Metastatic disease is common among parotid malignancies. The majority of primary tumours are located in the head and neck, but primary tumours below the clavicle must also be considered, especially in histological types not usually found in primary parotid or skin tumours. METHODS: We performed 644 consecutive parotidectomies between 1980 and 2012. Benign tumours were found in 555 patients (86%) and malignant tumours in 89 patients (14%). RESULTS: Of 89 malignant tumours, 39 were metastases (44%). In 5 cases, the primary tumour was located below the clavicle (6% of malignant tumours). A carcinoma of the bronchus was subsequently diagnosed in three patients: one patient had breast carcinoma and one renal cell carcinoma. CONCLUSION: The majority of metastases in the parotid gland arise from primary tumours of the head and neck. In 10-20% of metastases, the primary tumour arises below the clavicle. Parotid metastases can be the first clinical manifestation of a malignant tumour, and can also occur years after curative intent treatment. Histopathology and immunohistochemistry will offer clues to a possible metastatic process and to primary tumour location. Parotidectomy with complete excision of the tumour can be a curative measure or form an essential part of symptom control and should be considered in all but the most moribund patients.

The value of PET compared to MRI in malignant head and neck tumors.

BACKGROUND: Reliable diagnosis plays an important role in the early detection of head and neck tumors. The objective of this study was to compare the value and clinical relevance of magnetic resonance imaging (MRI) and positron emission tomography (PET) regarding the assessment and the identification of head and neck tumors. PATIENTS AND METHODS: From January 1, 2005, to January 1, 2007, 120 patients suffering from carcinomas of the oropharynx and larynx were examined by means of MRI and PET. RESULTS: The difference between sensitivity and specificity of MRI and PET was not significant with regard to the diagnosis of primary tumors, recurrence, or cancer of unknown primary. A statistically significant difference between both methods only occurred for detectron of malignant lymph nodes of size >10 mm. CONCLUSION: In particular, the assessment of small tumors by MRI and PET is characterized by a high number of false-negative findings. The future of diagnostic imaging is likely to be a combination of both techniques, as a hybrid technique.

Diagnostic relevance of metastatic renal cell carcinoma in the head and neck: An evaluation of 22 cases in 671 patients

ABSTRACT Purpose Renal cell carcinoma (RCC) is a malignant tumor that metastasizes early, and patients often present with metastatic disease at the time of diagnosis. The aim of our evaluation was to assess the diagnostic and differential diagnostic relevance of metastatic renal cell carcinoma (RCC) with particular emphasis on head and neck manifestations in a large patient series. Patients and methods We retrospectively evaluated 671 consecutive patients with RCC who were treated in our urology practice between 2000 and 2013. Results Twenty-four months after diagnosis, 200/671 (30%) of RCC had metastasized. Distant metastases were found in 172 cases, with 22 metastases (3.3%) in the head and neck. Cervical and cranial metastases were located in the lymph nodes (n=13) and in the parotid and the thyroid gland, tongue, the forehead skin, skull, and paranasal sinuses (n=9). All head and neck metastases were treated by surgical excision, with 14 patients receiving adjuvant radiotherapy and 9 patients receiving chemotherapy or targeted therapy at some point during the course of the disease. Five patients (23%) survived. The mean time of survival from diagnosis of a head and neck metastasis was 38 months, the shortest period of observation being 12 months and the longest 83 months. Discussion and conclusion Our findings show that while RCC metastases are rarely found in the neck, their proportion among distantly metastasized RCC amounts to 13%. Therefore, the neck should be included in staging investigations for RCC with distant metastases, and surgical management of neck disease considered in case of resectable metastatic disease. Similarly, in patients presenting with a neck mass with no corresponding tumor of the head and neck, a primary tumor below the clavicle should be considered and the appropriate staging investigations initiated.