Origins of and implementation concepts for upper airway stimulation therapy for obstructive sleep apnea.

Upper airway stimulation, specifically hypoglossal (CN XII) nerve stimulation, is a new, alternative therapy for patients with obstructive sleep apnea hypopnea syndrome who cannot tolerate positive airway pressure, the first-line therapy for symptomatic patients. Stimulation therapy addresses the cause of inadequate upper airway muscle activation for nasopharyngeal and oropharyngeal airway collapse during sleep. The purpose of this report is to outline the development of this first-in-class therapy and its clinical implementation. Another practical theme is assessment of the features for considering a surgically implanted device and the insight as to how both clinical and endoscopic criteria increase the likelihood of safe and durable outcomes for an implant and how to more generally plan for management of CPAP-intolerant patients. A third theme is the team building required among sleep medicine and surgical specialties in the provision of individualized neurostimulation therapy.

[Experience with laryngotracheal reconstruction in subglottic stenosis in a 30 years time period]. / Erfahrungen mit der laryngotrachealen Erweiterung bei subglottischen Stenosen in einem Zeitraum von 30 Jahren.

BACKGROUND: Severe subglottic stenosis is a difficult condition to manage. It can be treated by laryngotracheal reconstruction or cricotracheal resection. PATIENTS AND METHODS: In this retrospective study the experiences for treatment of isolated subglottic stenosis in 37 patients (age: 3-78 years; stenosis grading: 20 x grade II, 13 x grade III, and 4 x grade IV) by laryngotracheal reconstruction in a 30-years experience are presented. RESULTS: In 33 out of 37 patients (89.2 %) a sufficient subglottic patency (postoperative endoscopic finding: stenosis less than 30 %) was achieved by laryngotracheal reconstruction. However, 5 patients of this series had required revision of laryngotracheal recontruction and in 22 patients endoscopic removal of granulation tissue had been performed. Sufficient widening of the subglottic space had been possible in all grade II stenosis (20/20), in 11 out of 13 patients with grade III stenosis, and in 3 out of 4 patients with grade IV stenosis. In one child an accidental decannulation occurred and due to asphyxia an apallic syndrome developed. CONCLUSIONS: Even through laryngotracheal reconstruction is a demanding surgical technique requiring great experience it is an effective option for treatment of subglottic stenosis less than 90 %. For severe subglottic stenosis (> 90 %) treatment by laryngotracheal reconstruction is possible and should be considered if mobilisation of the trachea by scar tissue is suited to be worse or to extended cricotracheal stenosis is present, both being not good candidates for cricotracheal resection.

[Segmental tracheal resection for the treatment of tracheal stenoses]. / Tracheasegmentresektion zur Behandlung trachealer Stenosen.

BACKGROUND: Segmental tracheal resection is considered to be the standard treatment of tracheal stenoses. MATERIALS/METHODS: During the time period 1985-2002, segmental tracheal resection with a primary end-to-end anastomosis was performed in 117 patients with a cervical or upper thoracal stenosis of the trachea. The age distribution of the patients was between 7 and 77 years. Of the patients with a benign tracheal stenosis, sufficient data for a retrospective analysis were available in 101 patients. The length of the resected tracheal segments varied between 2 and 6 cm which required mobilisation of the trachea and the larynx and, if necessary, incision of the pulmonary ligament. RESULTS: In 5 patients a permanent damage of the recurrent laryngeal nerve was seen, of which 4 had undergone revision surgery and 10 months after surgery 93% presented with a large and stable tracheal lumen without any relevant restenosis. Due to a restenosis of 70-80% causing dyspnea at rest, 3% of the 101 patients had to undergo revision surgery. In 4% a mild and asymptomatic restenosis of 30-40% was seen which did not require any further treatment. CONCLUSION: These results demonstrate that segmental tracheal resection can safely and effectively remove stenotic tracheal segments of up to 6 cm and is therefore the treatment of choice.

[Styloid syndrome and its treatment]. / Das Styloidsyndrom und seine Behandlung.

BACKGROUND: An elongation of the styloid process or an ossification of the stylohyoid ligament can be the cause for a styloid syndrome and may lead to craniocervical pain, globus sensation and dysphagia. Pathophysiologically, the styloid syndrome is related to an irritation of the surrounding nerves, the carotid artery or the pharyngeal mucosa. There are various alternatives for its treatment. PATIENTS AND METHODS: This study analyzed retrospectively the data of eleven patients, who were treated for a styloid syndrome. All patients were placed on a stepwise therapy plan, which began with a medicamentous treatment, followed by a surgical treatment, if the problems persisted. The surgical approach included a transoral styloid fracture and/ or a surgical styloid shortening, which was carried out either transorally or transcervically. RESULTS: Three of the eleven patients presented no complaints after the medical treatment and did not require any further therapy. In two out of five patients, transoral fracturing of the styloid was successful. Six patients underwent surgical resection of the styloid process. In five cases a transoral route was used and in one cases a transcervical route. Postoperatively, four patients were free of symptoms and did not present any functional deficit. Two patients experienced severe complications with an ipsilateral medial cerebral artery infarction. These were related to a dissection of the internal carotid artery (ICA) in one case, and an arrosion bleeding of the ICA after the formation of an abscess of the parapharyngeal space in the other case. CONCLUSION: A stepwise therapy of the styloid syndrome including medicamentous treatment, transoral styloid fracture and resection of the styloid process has proven to be of value. If the styloid process can be palpated submucosally, a transoral resection may be chosen. However, using this route, the possibility of severe complications has to be taken into consideration, such as injury of the internal carotid artery.

[Tracheal rupture--a rare and dramatic emergency]. / Der Trachealabriss--Ein seltener und dramatischer Notfall.

A tracheal tear requires fast and proper treatment. A 55-year-old man working in a sewage pipe slipped and hit his neck on the edge of a concrete ring. The patient showed the following symptoms: cervical bruising, neck emphysema and increasing dyspnea. After several unsuccessful attempts to intubate the patient, a necklace incision was made immediately at the scene, under the suspected diagnosis of a torn trachea. A finger was used to look for the lower tracheal stump lying in the mediastinum. The lower stump was then intubated. In the hospital, an end-to-end anastomosis of the trachea as well as tracheotomy were performed on the patient. Because of the fracture of the larynx, an endolaryngeal stent was used to stabilize the lumen. Due to an injury to both laryngeal nerves, the patient suffered from dysphagea, whispered speech and dyspnea on minimal exertion as long-term side-effects. A lateralization of the vocal cord was made eight months later. Because of the quick assessment of the situation and proper treatment of the patient at the site of the accident, the patient was able to survive the injury.

Squamous cell carcinoma of the oropharynx: Ki-67 and p53 can identify patients at high risk for local recurrence after surgery and postoperative radiotherapy.

PURPOSE: To assess the prognostic value of biologic (p53, Ki-67) and clinical factors in squamous cell carcinoma of the oropharynx after radical surgery and postoperative radiotherapy (RT). METHODS AND MATERIALS: Between 1985 and 1995, a total of 102 patients with 104 tumor sites were entered onto the study. Fifty-five primary tumors (53%) involved the tonsils, 26 (25%) the soft palate, and 23 (22%) the base of the tongue. Median age was 53 years (range 36-80 years). The clinical T- and N-categories (UICC 1997) were: T1 (30), T2 (47), T3 (22), T4 (5), N0 (33), N1 (28), N2 (42), and N3 (1). Histologically-clear margins were achieved in all patients by initial surgery. Postoperative RT to the primary and regional lymphatics was given, to a total of 60 Gy in 6 weeks, and single daily fractions of 2 Gy. The expression of the nuclear p53- and Ki-67-labeling index (LI) was investigated by immunostaining using the monoclonal antibodies DO-7 and MIB 1. The nuclear p53-intensity (p53-I) was graded into 4 categories (0/+/++/) by densitometry. Median follow-up was 43 months (range 14-132 months). RESULTS: Cancer-specific survival, disease-free survival, and locoregional tumor control rates were 74%, 69%, and 75%, respectively, at 5 years. Significant prognostic factors for disease-free survival were: T-category (T1/2: 77% vs. T3/4: 53%, p = 0.02), tumor site (tonsils: 79% vs. soft palate: 70% vs. base of tongue: 45%, p = 0.05), duration of RT (< or = 46 days: 80% vs. > 46 days: 60%, p = 0.04), Ki-67 LI (< or = 20%: 84% vs. > 20%: 49%, p = 0.006) and p53-I (0/+: 56% vs. ++/ : 79%, p = 0.008). A significant prognostic impact on locoregional control was noted for the duration of RT (< or = 46 days: 86% vs. > 46 days: 68%, p = 0.01), tumor site (tonsils: 88% vs. soft palate: 67% vs. base of tongue: 51%, p = 0.02), Ki-67 LI (< or = 20% LI: 87% vs. > 20% LI: 56%, p = 0.018), and the p53-I (0/+: 58% vs. ++/ : 88%, p = 0.0006). On multivariate analysis, the p53 nuclear intensity (p = 0.002) and the Ki-67 index (p = 0.01) remained the only significant factors for locoregional control. CONCLUSION: Ki-67 labeling index above 20% and a weak p53 nuclear intensity (0/+) are both able to identify patients with squamous cell carcinoma of the oropharynx being at high risk for local recurrence after surgery and postoperative RT. Consequently, in this subgroup an intensification of treatment may be contemplated in prospective trials.

Neurothekeoma, a rare tumour of the tongue.

Neurothekeomas are benign tumours mostly arising in the face and upper limbs predominantly in young women. Histologically they can be classified as cellular or myxoid, and complete surgical resection is the treatment of choice. In this case of a neurothekeoma located in the anterior tongue of a child, cryotherapy was used as the treatment modality, in order to avoid a greater loss of tongue function.

Middle ear adenocarcinoma with intracranial extension. Case report.

Middle ear adenocarcinoma is a very rare, locally invasive neoplasm assumed to arise from the middle ear mucosa. Although endolymphatic sac tumor (aggressive papillary middle ear tumor) and jugulotympanic paraganglioma may show brain invasion, intracranial extension of histologically confirmed middle ear adenocarcinoma has not been previously reported. The authors describe a 53-year-old man who suffered from otalgia and tinnitus for more than 10 years and from neurological deficits for 1 year due to a large temporal bone tumor that invaded the temporal lobe. A combined neurosurgical and otolaryngological resection was performed. Pathological analysis revealed a low-grade adenocarcinoma of a mixed epithelial-neuroendocrine phenotype, which showed a close histological similarity to, and topographical relationship with, middle ear epithelium. The authors conclude that middle ear adenocarcinoma belongs to the spectrum of extracranial tumors that have possible local extension to the brain.

[Nasopharyngeal carcinoma: only irradiation or simultaneous radiochemotherapy?]. / Nasopharynxkarzinom: nur Bestrahlung oder simultane Radiochemotherapie?

BACKGROUND: Between 1979 and 1997, a total of 92 patients with primary nasopharyngeal carcinoma were treated at the Hospitals of the University of Erlangen. Until 1988, radiotherapy alone was the treatment of choice and simultaneous radiochemotherapy was consistently applied thereafter. This retrospective analysis was performed to evaluate the influence of concurrent radiochemotherapy on survival and to identify possible prognostic factors on cause-specific survival-, locoregional tumor control- and distant-metastases-free survival rates. PATIENTS AND METHODS: Fifty-three patients (58%) received treatment by radiotherapy alone and 39 (42%) underwent primary radiochemotherapy with 2 courses of 5-FU and cisplatin. Median total dose to the bilateral neck region was 60 Gy (range, 50 to 62 Gy), and 74 Gy (range, 56 to 88 Gy) to the primary tumor. Median follow-up of the surviving patients was 8 years. RESULTS: Following radiochemotherapy and radiotherapy alone, the 5-year-survival rates were 67% and 48%, respectively (p = 0.06). Female patients had a survival advantage as compared to male patients (5-year-survival rate 77% vs 44%, p = 0.01). Patients with and without cranial nerve palsy at presentation had survival rates of 0% and 61%, respectively, at 5 years (p = 0.01). Distant-metastases-free survival was influenced by the following factors: lymph-node involvement (NO: 82% vs N1 to N3: 68%, p = 0.04), gender (female: 88% vs male: 64%, p = 0.01), type of treatment (radiochemotherapy: 86% vs radiotherapy: 63%, p = 0.02) and cranial nerve involvement (76% without and 42% with involvement, p = 0.04). CONCLUSIONS: In primary nasopharyngeal carcinoma simultaneous radiochemotherapy can significantly reduce distant metastases and improve survival as compared to radiotherapy alone. Since late toxicity rates were similar in both treatment groups and the slightly increased acute side effects following radiochemotherapy were effectively compensated by standard supportive care, patients with advanced nasopharyngeal carcinoma may benefit from simultaneous radiochemotherapy.

Transoral laser surgery of supraglottic cancer: follow-up of 141 patients.

OBJECTIVE: To determine the role of transoral laser resection of supraglottic carcinomas. DESIGN: Retrospective unicenter study of the oncologic results of transoral carbon dioxide laser microsurgery for supraglottic carcinomas performed between February 1979 and December 1993. Median follow-up was 37 months. SETTING: University hospital academic tertiary referral center. PATIENTS: We reviewed the medical records of 141 patients (a consecutive sample of 131 men and 10 women; mean age, 60 years) with histologically proven supraglottic carcinomas undergoing transoral laser surgery, possibly in combination with neck dissection or radiotherapy. Stage distribution of patients was as follows: stage I, 23.4%; stage II, 25.5%; stage III, 16.3%; and stage IV, 34.8% (according to the Union Internationale Contre le Cancer staging system). MAIN OUTCOME MEASURES: Recurrence-free survival rates and local and regional recurrence rates. RESULTS: Five-year recurrence-free survival rates were as follows: the whole case load, 65.7%; stage I, 85.0%; stage II, 62.6%; stage III, 74.2%; and stage IV, 45.3%, according to the Union Internationale Contre le Cancer staging system. The local and regional recurrence rates were 16.3% and 9.9%, respectively. CONCLUSIONS: The oncologic results of transoral carbon dioxide laser surgery are satisfying if clean surgical margins (R0 resection) can be reached. In patients in whom tumor-free margins are not achieved (R1 and R2 resection) and transoral revision is not possible, transcervical procedures (partial or total laryngectomy) should be performed. The indication for transoral supraglottic laryngectomy in T3 lesions should be considered with restraint.

[Function preserving surgery of glomus jugulare tumors. An achievable goal?]. / Funktionserhaltende Chirurgie von Glomus-jugulare-Tumoren. Ein realisierbares Ziel?

In this retrospective study, oncologic and functional results of 24 patients treated for glomus jugulare tumor stages C and D are reported. The surgical approach used was a combined transmastoid-transcervical approach, which was modified according to individual tumor growth. As needed, this was combined with a transtemporal or retrosigmoid approach. Complete tumor removal resulted in a cure rate of 100%. Surgically induced cranial nerve palsies developed in 38% of the patients. In 54% of cases it was possible to retain middle ear function. Seven patients had incomplete tumor removal requiring postoperative irradiation, with tumor progression occurring in 2 patients. Radical tumor removal was modified by efforts to reduce mutilating resections. These results show that individually tailored and combined multidirectional surgical approaches can allow total tumor removal to be performed with lower morbidity.

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.

Endoscopic endonasal dacryocystorhinostomy: results in 56 patients.

Fifty-six patients with a complete stenosis of the nasolacrimal duct were treated by endoscopically controlled intranasal dacryocystorhinostomy according to West. Forty-four patients had idiopathic stenosis and 12 had posttraumatic scarring. Revision surgery was done in 11 of these 56 cases (8 patients with a previous external Toti procedure, and 3 patients with previous endonasal surgery). Altogether, 95% of the patients were symptom-free (86%) or felt improved (9%) postoperatively. Surgical revision was successful in 82%. Of patients with an "idiopathic" stenosis, 84% were healed and an additional 11% were improved. The success rate in the 12 patients with posttraumatic stenosis was 92%. Endoscopic duct surgery is a highly successful procedure with a low complication rate, the worst complication being persistence of symptoms.

Malignant tumors of the anterior cranial skull base.

Malignant tumors of the anterior cranial skull base are still a challenge for radical surgical treatment. Several different techniques and approaches have been developed over the years and the results, with mortality rates over 50%, are still not encouraging. Here we present our results of an interdisciplinary, one-stage, neurohino transfronto-transbasal surgical approach in twelve patients with such tumors. The long-term survival rate in our patients is now 83% with a mean postoperative follow-up of 19.3 months. Two patients died due to early recurrencies and metastasis after 10 and 13 months after initial treatment and postoperative irradiation. Another five patients with a follow-up of 34.2 months have had tumor recurrencies diagnosed at 19.5 months postoperatively. These patients have survived their recurrent tumor for 14.7 months. Five patients, 41% of the whole group, have been living without evidence of tumor recurrence for between 2 and 35 months.

[Results of temporary interstitial iridium 192 implantation in head and neck tumors]. / Ergebnisse der temporären interstitiellen Iridium-192-Implantation von Kopf-Hals-Tumoren.

In order to improve local tumor control in advanced head and neck tumors, a temporary interstitial iridium-192 implantation (40 to 50 cGy/h) was performed as a boost therapy (20 to 30 Gy at the surface of the target volume). This treatment was part of a multimodal therapy conception for primary tumors (N = 55) as well as for recurrences (N = 22). Local control was achieved in 89% (49/55) of patients treated for primary tumors. Complications appeared in the form of soft tissue necroses in 55% (30/55) and in the form of osteoradionecrosis of the mandible in 7% (4/55) of the patients. The authors discuss as possible reasons for this high complication rate: implantation volume too large or total activity too high, activities of the individual iridium-192 seeds to high, setting of radiation sources too close together, total dose too high, disturbed reparation capacity of sound tissues due to preceding operation and chemotherapy, premature test biopsies in the area of implantation, lacking oral hygiene and dental care by uncooperative patients. A local control rate of 50% was achieved by the treatment of recurrences, but this has no importance for the course of this tumor disease which is fatefully determined by the formation of remote metastases.

[Early and long-term results following tracheal segment resection]. / Früh- und Langzeitergebnisse nach Tracheasegmentresektion.

We analysed the medical records of 41 patients who had undergone sleeve resection of the trachea for cicatricial stenosis of the airway at least 1 year previously. An attempt was made with the aid of a questionnaire and follow-up examination to determine the long-term results of these patients. Thirty-two of the patients were available for review. In 22 patients, respiration at rest and during exertion was adequate. Six patients had dyspnoea under stress due to a medical cause, or it was not possible to assess respiration under conditions of exertion. In 2 patients in whom a very long segment of the trachea had been resected, a recurrent tracheal stenosis had led to dyspnoea on exertion, although respiration at rest was adequate. Two patients had to undergo further surgery for dyspnoea at rest. In both patients, in addition to the stenosis of the trachea, narrowing of the glottis caused by paralysis of the vocal cords in the paramedian position was also present. Overall the results of tracheal sleeve resection were good. The great advantage of this method in comparison with other procedures is the fact that a stenosis of the trachea can be eliminated in a single operation with a high chance of success.

Neuro-rhinosurgical treatment of aesthesioneuroblastoma.

The results of a combined neuro-rhinosurgical procedure in eight cases of aesthesioneuroblastoma are presented. All patients were suffering from tumours in the advanced stage (stage C according to Kadish). Diagnosis was established by the clinical history, neuro-radiological imaging and by endoscopic endonasal biopsy. Contrary to most reports in the literature the authors performed a one step operative removal of the whole tumour mass by a combined transcranial-transbasal approach alone. A second transfacial operation was unnecessary in all our cases. To the best of our knowledge only Loew (see Jakumeit 1971) already in the 1960ties used a comparable one step transcranial approach for tumour removal. The long-term survival rate in our patients is 50%, a result comparable to reported series in the literature. Mortality is due to early recurrences and metastases within a few months after the initial treatment including post-operative irradiation. Four patients are living without evidence of tumour recurrence 1.5 to 5 years after treatment. The authors surgical technique is presented in detail and compared with the results of other treatment modalities.

[Cervical lymph node metastases from an unknown primary tumor]. / Halslymphknotenmetastasen bei unbekanntem Primärtumor.

From 1978 through August 1986, 32 patients with lymph node metastases of the neck and unknown primary tumor were treated at the Radiotherapeutic Hospital of the University Erlangen-Nürnberg. Most of the cases were large metastases from squamous cell carcinomas or anaplastic carcinomas. The patients were treated by surgery and postsurgical radiotherapy or radiotherapy alone. In nearly all patients the target volume comprised both sides of the neck including the median structures as well as the base of the tongue and the nasopharynx. A dose of at least 50 Gy was aimed at, which was given within five weeks by individual doses of 2 Gy each. The survival at three years is 70% and at five years 52%. Out of twenty patients irradiated with more than 50 Gy following lymph node extirpation or radical excision of the lymph nodes of the neck, sixteen are tumor-free. The five year survival of this group is 80%. The results of radiotherapy alone are unsatisfactory, because only two out of nine patients are alive with follow-up periods of less than one year. Two primary tumors were found after the end of treatment. Both were situated within the ORL areas beyond the ancient irradiation fields, and both were developed by patients who at first had only been treated by local irradiation. Half of the patients with lymph node metastases of the neck and unknown primary tumors can be cured by complete tumor excision and postsurgical irradiation. The target volume of radiotherapy comprises both sides of the lymph drainage area of the neck as well as the mucous membranes of the ORL region including nasopharynx and base of the tongue. The dose is at least 50 Gy which is given after surgery with conventional fractionation.

[Significance of percutaneous endoscopically controlled gastrostomy in the prevention and therapy of esophagotracheal fistula following long-term intubation]. / Bedeutung der perkutanen endoskopisch kontrollierten Gastrostomie zur Prophylaxe und Therapie der Osophagotrachealfistel nach Langzeitintubation.

An esophago-tracheal fistula, which developed during long-term artificial ventilation, is a vital threat to the life of a patient. The esophago-tracheal fistula is caused by pressure lesion of the mucosa of the posterior tracheal and anterior esophageal wall. The adverse mechanic factors are the blocked tube cuff on the one hand and the nasogastric tube being usually required for enteral nutrition on the other hand. Replacement of a nasogastric tube through a percutaneous, endoscopically controlled gastrostomy relieves the esophagus and thus prevents pressure lesion of the anterior esophageal wall. A percutaneous endoscopic gastrostomy, if performed in time, is suggested to reduce the incidence of an esophago-tracheal fistula, which develops in the course of long-term artificial ventilation.