[ENT medicine and head and neck surgery in the G-DRG system 2008]. / Die HNO-Heilkunde, Kopf- und Hals-Chirurgie im G-DRG-System 2008.

BACKGROUND: Further developments in the German DRG system have been incorporated into the 2008 version. For ENT medicine and head and neck surgery significant changes concerning coding of diagnoses, medical procedures and concerning the DRG-structure were made. METHODS: Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2007 and 2008 based on the publications of the German DRG institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS: Changes for 2008 focussed on the development of DRG structure, DRG validation and codes for medical procedures. The outcome of these changes for German hospitals may vary depending on the range of activities. CONCLUSION: The G-DRG system has gained in complexity again. High demands are made on correct and complete coding of complex ENT and head and neck surgery cases. Quality of case allocation within the G-DRG system has been improved. For standard cases quality of case allocation is adequate. Nevertheless, further adjustments of the G-DRG system especially for cases with complex neck surgery are necessary.

[ENT and head and neck surgery in the German DRG system 2007]. / HNO-Heilkunde, Kopf- und Hals-Chirurgie im G-DRG-System 2007.

BACKGROUND: The German DRG system has been further developed into version 2007. For ENT and head and neck surgery, significant changes in the coding of diagnoses and medical operations as well as in the the DRG structure have been made. RESULTS: New ICD codes for sleep apnoea and acquired tracheal stenosis have been implemented. Surgery on the acoustic meatus, removal of auricle hyaline cartilage for transplantation (e. g. rhinosurgery) and tonsillotomy have been coded in the 2007 version. In addition, the DRG structure has been improved. Case allocation of more than one significant operation has been established. CONCLUSION: The G-DRG system has gained in complexity. High demands are made on the coding of complex cases, whereas standard cases require mostly only one specific diagnosis and one specific OPS code. The quality of case allocation for ENT patients within the G-DRG system has been improved. Nevertheless, further adjustments of the G-DRG system are necessary.

[Possibilities and limitations for the representation of ENT medicine in the G-DRG reimbursement system. Results of the DRG evaluation project]. / Möglichkeiten und Grenzen einer Abbildung der HNO-Heilkunde im G-DRG-System. Ergebnisse des DRG-Evaluationsprojektes.

BACKGROUND: To improve the representation of ENT medicine in the German diagnosis related groups (G-DRG) reimbursement system, the German Association for ENT Medicine and the ENT Professional Medical Association, in cooperation with the DRG-Research Group of the University Hospital of Muenster, undertook a DRG evaluation project. METHOD: A retrospective analysis was carried out of the DRG data records from 93,605 cases taken at 39 ENT institutions in 2003. A prospective collection of data from 25,666 cases, including defined expenditure data within a 4 month period in 2004, was also made. RESULTS: The number of cases per ENT institution ranged from 274 to 2,556. The mean case-mix was 792.0 and the mean case-mix index was 0.84. A total of 60.5% of the patients were male and 39.5% female, with an average age of 43.3 years. The mean patient clinical and complexity level (PCCL) was 0.72. Considerable adjustments have to be made, especially in oto-, rhino- and sinus-surgery. Allocation according to the complexity of the surgical procedure is mandatory and requires a revision of the German Catalogue of Medical Procedures. A DRG differentiation based on the PCCL should be implemented more frequently. Diagnostic endoscopies should be allocated via surgical partitioning. CONCLUSION: The adjustment proposals based on these results will gradually lead to an improved allocation of ENT medical procedures within the G-DRG system in 2006 and later.

De novo antimicrobial peptides with low mammalian cell toxicity.

De novo antimicrobial peptides with the sequences: (KLAKKLA)n, (KLAKLAK)n (where n = 1,2,3), (KALKALK)3, (KLGKKLG)n, and (KAAKKAA)n (where n = 2,3), were prepared as the C-terminus amides. These peptides were designed to be perfectly amphipathic in helical conformations. Peptide antibacterial activity was tested against Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus. Peptide cytotoxicity was tested against human erythrocytes and 3T3 mouse fibroblasts. The 3T3 cell testing was a much more sensitive test of cytotoxicity. The peptides were much less lytic toward human erythrocytes than 3T3 cells. Peptide secondary structure in aqueous solution, sodium dodecylsulfate micelles, and phospholipid vesicles was estimated using circular dichroism spectroscopy. The leucine/alanine-containing 21-mers were bacteriostatic at 3-8 microM and cytotoxic to 3T3 cells at about 10 microM concentrations. The leucine/alanine- or leucine/glycine-containing 14-mers and the leucine/glycine 21-mer were bacteriostatic at 6-22 microM but had much lower cytotoxicity toward 3T3 cells and higher selectivities than the natural antimicrobial peptides magainin 2 amide and cecropin B amide. The 7-mer peptides are devoid of biological activity and of secondary structure in membrane mimetic environments. The 14-mer peptides and the glycine-containing 21-mer show modest levels of helicity in model membranes. The leucine/alanine-containing 21-mer peptides have substantial helicity in model membranes. The propensity to alpha-helical conformation of the peptides in amphipathic media is proportional to their 3T3 cell cytotoxicity.

Efficacy of botulinum toxin A for treatment of upper esophageal sphincter dysfunction.

OBJECTIVES: To investigate the efficacy of botulinum toxin A (BTA)-induced chemodenervation of the upper esophageal sphincter (UES) in patients with dysphagia and UES dysfunction. STUDY DESIGN: Prospective clinical trial in 10 selected patients with pure UES dysfunction. METHODS: In each patient 30 units of BTA were injected into the UES under brief general anesthesia. Videofluoroscopic swallowing study (VSS) was done and a clinical symptom score was determined before and after treatment. RESULTS: On VSS relative opening of the UES improved in all patients (mean +/- SD: 47 +/- 14% before versus 71 +/- 24% after treatment; P < .01). Hypopharyngeal retention or laryngeal penetration of barium was significantly reduced in four of seven patients. Clinical symptom scores improved in all patients. One patient was free of symptoms, mild dysphagia persisted in six patients, and moderate dysphagia persisted in three patients. CONCLUSIONS: Our results support the use of BTA in selected patients with pure UES dysfunction. Its efficacy is limited by the possibility of a persistent structural stenosis of the UES and the risk of BTA diffusion into the larynx or hypopharynx.

Monophasic synovial sarcoma of the neck in an 8-year-old girl resembling a thyroglossal duct cyst.

Synovial sarcomas of the head and neck are rare. Typically, they are localized laterally in the parapharyngeal space. We report the case of an 8-year-old girl with a monophasic round cell synovial sarcoma of the anterior neck, clinically resembling a thyroglossal duct cyst. Histologic, immunohistochemic and cytogenetic findings are presented with a brief review of the literature. This case reaffirms the importance of considering malignant neoplasms in the differential diagnosis of pediatric neck masses.

Histomorphologic reaction patterns in cervical lymph nodes of different neck sites.

Immunologically based studies of host-tumor interactions have gained popularity in head and neck oncology and histopathological determination of lymph node reactivity has been shown to correlate with survival. However, little is known about lymph node reaction patterns in the "normal" neck. In a prospective histomorphologic study 1,024 cervical lymph nodes (CLN) were dissected at autopsy from 25 selected cadavers free of head and neck disease. To investigate regional differences of immune reactivity, these lymph nodes were grouped according to neck levels. 242 CLN groups of 50 neck sites were microscopically classified into one of four distinct histomorphologic immune reaction patterns (RP). 14.5% of CLN groups showed lymphocyte predominance (RP 1), 12% showed germinal center predominance (RP 2), 63.2% were unstimulated (RP 3) and 10.3% displayed regressive changes (RP 4). Distribution of RP was highly significant according to neck level (p<0.001): RP 1 and RP 2 were common in the submandibular (Level I) and the upper parajugular groups (Level II) whereas RP 4 was more typical in the inferior parajugular groups (Level IV) and posterior triangle (Level V). RP 2 and RP 4 showed significant correlation to age and general condition. These findings suggest that tumor independent lymph node reactivity related to neck site, age and general condition of the patient needs to be differentiatedfrom tumor induced patterns in future morphologic investigations of cervical lymph nodes in patients with head and neck carcinoma.

Hyperkinetic gallbladder: an indication for cholecystectomy?

Cholecystectomy may benefit children with biliary colic without stones on ultrasound (US) or low ejection fraction on cholecystokinin-hepatobiliary iminodiacetic acid (CCK-HIDA) scan. Children with symptomatic biliary colic and abnormal HIDA scan, specifically those with high ejection fractions, may benefit from cholecystectomy. All patients younger than 18 years old undergoing cholecystectomy from 2008 to 2012 in our practice were reviewed. Patients with a negative US and CCK-HIDA ejection fractions 80 per cent or greater were included in the study. Patient data were extracted from charts, whereas postoperative symptoms were obtained by phone interviews. Of 174 patients who underwent cholecystectomy, 12 (7%) met study criteria. All patients (12 of 12) had evidence of cholecystitis on the final pathology note. All 11 patients contacted had relief of colic after gallbladder removal with a mean follow-up of 16 months. A subset of pediatric patients with high ejection fractions on CCK-HIDA and symptomatic biliary colic may have symptomatic relief with cholecystectomy.

[Expert assessment of adenocarcinomas of the nasal cavity and the paranasal sinuses caused by wood dust]. / Aktualisierung der Hinweise zur Begutachtung holzstaubassoziierter sinunasaler Adenokarzinome (BK 4203)1.

BACKGROUND: Adenocarcinomas of the nasal cavity and the paranasal sinuses after occupational exposure to sawdust from oak and beech have been listed as occupational diseases in Germany since 1988. Given that modes of treatment have changed, we analyzed the guidelines based on the recommendations of Hartung et al. for developing an expert assessment on reduced earning capacity. MATERIALS AND METHODS: A retrospective analysis of 43 cases which had been evaluated between March 1994 and February 2007 for an occupational disease #4203, in the Ear-Nose-Throat clinic of the Münster University Hospital, Germany. RESULTS: Following the guidelines of Hartung et al., it was impossible to formally classify 21 of 43 cases (48.8 %) in an unambiguous manner. This was primarily due to the assessment of the results of radiotherapy, either adjuvant or therapeutic, as well as the grading of postoperative dysfunction in the area of the sinuses operated on (Rhinitis, Ozaena). Suggestions for a revision of the classification system include a modified assessment of radiotherapy as well as evidence for grading post-therapeutic inflammations of the sinus operated on based on the need for further care. These changes enable all cases in question to be classified unambiguously. CONCLUSIONS: The use of the revised guidelines is recommended for expert assessment of adenocarcinomas of the nasal cavity and the paranasal sinuses caused by wood dust.

[ENT relevant changes in the German OPS Procedure Classification System for 2006]. / HNO-relevante Anderungen des Operations- und Prozedurenschlüssels (OPS) ab 2006.

BACKGROUND: Classification of surgical and medical procedures is of increasing relevance for health care financing. From this viewpoint, classification according to the German "Operations- und Prozedurenschlüssel" (OPS) was frequently inadequate so far. METHODS: In the course of a comprehensive DRG evaluation project, deficits of the economic classification of ENT-medicine were identified. Based on these findings, proposals for further improvement of the OPS were developed. RESULTS: An improper medical economic classification was identified for common surgical procedures on middle ear, nose and paranasal sinuses, and for coding of prosthetic voice restoration. In agreement with the German Institute for Medical Documentation and Information (DIMDI) the OPS was revised accordingly. CONCLUSIONS: Significant modifications of the OPS will take place at January 1 (st) 2006, which are of great impact for health care financing by the G-DRG-System and in the context of outpatient surgery.

Primary role of growth-related oncogene-alpha and granulocyte chemotactic protein-2 as neutrophil chemoattractants in chronic rhinosinusitis.

BACKGROUND: The aetiology of chronic rhinosinusitis (CRS) remains unclear. The purpose of this study was to investigate neutrophil-attracting chemokine patterns in CRS without nasal polyposis. METHODS: The biological activity of the chemokines was identified using a two-step high-performance liquid chromatography (HPLC) technique combined with a bioassay in extracts from 55 CRS patients, and in the turbinate mucosa (TM) of patients (N=51) undergoing septumplasty. The biologic activity of each chemokine was assessed using blocking antibodies to chemokines. Immunolocalization of detected neutrophil chemokines was performed by quantitative evaluation of immunohistochemistry. Besides, PCR analysis was performed to quantify neutrophil chemokine mRNA. RESULTS: In CRS, the chemokines primarily detected by two-step HPLC were growth-related oncogene-alpha (GRO-alpha) and the granulocyte chemotactic protein-2 (GCP-2). Blocking of GCP-2 and GRO-alphad each resulted in chemotaxis inhibition rates of 43.3% and 35.9%, respectively, whereas anti-IL-8 and anti-ENA-78 had no effect. Both GCP-2 and GRO-alphad were generally synthesized by the surface epithelium and mucosal glands while GRO-alpha in particular was synthesized by endothelial cells, as shown by immunohistochemistry. The concentrations of the chemokines IL-8 and epithelial cell-derived neutrophil attractant-78 (ENA-78) were low in CRS and TM. CONCLUSION: It appears that both GRO-alpha and GCP-2 contribute to neutrophil chemotaxis in CRS, whereas IL-8 and ENA-78 appear to be of secondary importance for the chemotaxis of neutrophils in this condition. The expression of chemokines in mucosal gland cells is the main phenomenon involved in constitutive neutrophil chemotaxis in the TM.

[Malignant fibrous histiocytoma in the parotid gland. Case series and literature review]. / Maligne fibröse Histiozytome in der Glandula parotis. Fallserie und Literaturübersicht.

BACKGROUND: Malignant fibrous histiocytoma (MFH), a soft tissue sarcoma that is predominantly localized in the extremities and retroperitoneum, rarely occurs in the head and neck. This study presents the clinicopathological features of three patients with MFH of the parotid gland treated at the ENT department of the University Hospital of Muenster (Germany) between 1991 and 2002. PATIENTS: The clinical course of all three patients was defined by a rapidly growing mass in the parotid area. Surgical therapy was the first treatment of choice. In two patients, radical parotidectomy was performed, whereas one patient underwent partial parotidectomy. Selective neck dissection was performed in one case. In two cases, post-surgical treatment involved radiation and/or chemotherapy. Two patients died as a consequence of local recurrence within the first year after diagnosis, whereas one patient is alive and free of disease after a follow up of 14 months. CONCLUSION: Our own experiences, taken together with those reported in the literature, suggest that clear surgical margins are probably the most important factor for avoiding a recurrence and to improve disease free survival.

The effect of endogenous nitric oxide on mechanical ciliostimulation of human nasal mucosa.

BACKGROUND: Endogenous nitric oxide (NO) production by the inducible NO-synthase is enhanced in the nasal respiratory epithelium of patients with allergic rhinitis. Recent experimental data suggest endogenous NO to be strongly involved in the regulation of ciliary activity, the driving force of the mucociliary transport system. OBJECTIVE: In this study, we investigated the effect of endogenous NO on mechanical stimulation of ciliary activity in a nasal mucosa explant model. METHODS: Cultures of nasal mucosa explants were incubated with TNF-alpha and bacterial lipopolysaccharides (LPS) to enhance endogenous NO production. Direct in vitro NO imaging was performed by the fluorescent NO-indicator DAF-2 DA and laser scanning confocal microscopy. Ciliary beat frequency (CBF) was determined using a photoelectric technique. Mechanical stimulation was performed by two consecutive flow increments in a closed perfusion chamber. Endogenous NO-synthesis was blocked by l-NAME before the second flow stimulation. RESULTS: Under control conditions the mean rise of CBF relative to baseline was 30.2% during the first flow increment and 30.7% during the second flow increment. Blocking of the endogenous NO synthesis in TNF-alpha/LPS-stimulated cultures reduced baseline CBF by 10.6+/-2.1% (P<0.05) but the effect of mechanical ciliostimulation on CBF remained unchanged (36.0% vs. 38.2%). CONCLUSION: In conclusion, endogenous NO- and Ca(2+)-dependent mechanical stimulation of ciliary activity probably use independent intracellular signalling pathways. The combination of both effects on ciliary activity is likely to improve the local defence against inhaled allergens in patients with nasal allergies.

[The German DRG system and its effect on imaging quality in ENT, and head and neck surgery]. / Das G-DRG-System 2006 und seine Auswirkungen auf die Abbildungsqualität der HNO-Heilkunde und Kopf- und Hals-Chirurgie.

BACKGROUND: The new G-DRG system for 2006 was published in September 2005. This article presents, analyses, and comments essential changes in the G-DRG system for 2006 and their consequences for ENT-Medicine. RESULTS: The complexity of the G-DRG system has increased significantly. In 2006, the case allocation will be more differentiated for common surgical procedures on the middle ear, nose, paranasal sinuses, salivary glands, and for head and neck cancer. Furthermore, the patient's age and the clinical and complexity level (PCCL) will be of increased relevance in selected case constellations. However, diagnostic endoscopies with rigid instruments will still not be regarded as OR procedures. CONCLUSION: Essential adjustments proposed by the German Association for ENT Medicine (DGHNOKHC) and the ENT Medical Professional Association (HNO-Berufsverband) have been made, and the quality of case allocation of ENT-patients within the G-DRG system improved. Nevertheless, further adjustments to the G-DRG system are necessary.

[G-DRG System 2005. Analysis and evaluation of significant changes from the viewpoint of HNO medical science]. / G-DRG-System 2005. Analyse und Bewertung wesentlicher Anderungen aus Sicht der HNO-Heilkunde.

With the release of the new Global Case Agreement by Self Administration in Public Health on the 16 September 2004, the adjustment of the G-DRG System for the year 2005 was completed. Otorhinolaryngology, and head and neck surgery face several changes in the fields of diagnosis and procedural coding (ICD-10-GM 2005, OPS-301 2005), G-DRG case allocation, and extra reimbursements for special interventions. Despite some considerable improvements, substantial problems remain unsolved. This paper presents and comments on the key points of the G-DRG System for 2005 for otorhinolaryngology, and head and neck surgery.

The effect of antiallergic intranasal formulations on ciliary beat frequency of human nasal epithelium in vitro.

The nasal mucociliary clearance is an important defense mechanism of the upper respiratory tract. It is known to be influenced by many pharmacologic substances. We investigated the effects of three topical intranasal antiallergic formulations containing disodium cromoglycate (DNCG), dimethindene maleate (DMM), and azelastine-HCL (AZL) on nasal ciliary beat frequency (CBF) in vitro. Nasal ciliated cells were harvested from 16 healthy volunteers. Cells were diluted 1:10 in culture medium and incubated with a placebo formulation (PLAC), containing 0.022% benzalkonium chloride, which was part of all formulations, a registered 2% formulation of DNCG, a 0.1% formulation of DMM, and a registered 0.1% formulation of AZL. After an incubation period of 20 min, CBF was registered by a photoelectric measurement device. Under control conditions (CONTROL), CBF was 11.4 +/- 1.3 Hz. PLAC reduced CBF to 9.7 +/- 2.3 Hz (NS). DNCG reduced CBF to 9.7 +/- 2 Hz (NS). DMM reduced CBF to 7.2 +/- 1.7 Hz (P < or = 0.05 vs CONTROL, NS vs PLAC), and AZL reduced CBF to 0.9 +/- 1.8 Hz (P < or = 0.001 vs CONTROL, P < or = 0.001 vs DNCG, P < or = 0.001 vs PLAC). In conclusion, a possible influence of antiallergic intranasal formulations on nasal ciliary function has to be considered in clinical application.

[Use of high frequency cinematography in diagnosis of globus sensation]. / Zum Einsatz der Hochfrequenzkinematographie in der Diagnostik des Globusgefühls.

BACKGROUND: Globus pharyngis is a frequent symptom in patients who consult an otolaryngologist. In many cases, routine diagnostic work-up including history, clinical examination, and barium swallow fail to revealing the underlying pathogenesis. PATIENTS AND METHOD: In a retrospective study, we present 51 selected patients suffering from globus pharyngis of unknown origin who were investigated by high-speed cineradiography in a standardized manner. RESULTS: Twenty-four of the patients enrolled in the study (47.1%) showed functional and/or structural swallowing disorders. In 13 cases (25.5%) dyskinesias of the superior esophagus sphincter muscle were found. Five of these patients (9.8%) also had an inconstant hypopharyngeal diverticulum. Six cases (11.8%) showed laryngeal penetration or tracheal aspiration. In four cases (7.8%) functional disorders of pharyngeal, and in three cases (5.9%) functional disorders of oral bolus transport were found. Furthermore one hypopharyngeal web (1.9%) and two benign tumors (3.9%) were detected. In many cases, varying combinations of these findings occurred. CONCLUSION: Using high-speed cineradiography for evaluation of globus pharyngis results in an increased incidence of pathologic findings, and thus is an important method for interdisciplinary diagnostic work up of patients suffering from this symptom.