Barbed suture in neck dissection: a randomized clinical study on efficacy, safety and aesthetic outcome.

PURPOSE: The resection of lymph nodes/neck dissection is a typical part of the surgical treatment of head and neck malignancies. The aim of this study was to compare subcutaneous closure using single knotted, braided suture (VicrylTM, standard arm) with continuous self-locking, monofilament barbed suture (V-LocTM, experimental arm). METHODS: Neck Lock was a randomized clinical trial at a single tertiary referral center. It was conducted from 2016 till 2022 with a follow-up period of 3 months. Assessment of safety and aesthetic outcome was double-blinded. 68 patients were randomized after application of exclusion criteria. Subcutaneous wound closure was performed in an intrapatient randomized fashion for suture technique. The primary endpoint was the duration of subcutaneous sutures. Wound healing and scar formation were recorded at multiple postoperative intervals as secondary endpoints. RESULTS: The median age was 61 years, 89.7% were male. 92.6% suffered from a squamous cell carcinoma. There was a significant difference in median subcutaneous suture time (p = 0.024) between the experimental (6:11 ± 2:30 min) and standard (7:01 ± 2.42 min) arms. There was no significant difference in safety when assessing adverse events (AEs). At least one AE occurred in 14.7% vs. 5.9%, for barbed and smooth sutures respectively (p = 0.16). CONCLUSION: For neck dissection of head and neck malignancies, subcutaneous wound closure with self-locking sutures offers significant time savings over the single knot technique with similar safety and aesthetic results. TRIAL REGISTRATION INFORMATION: The trial was registered with WHO acknowledged primary registry "German Clinical Trials Register" under the ID DRKS00025831 ( https://drks.de/search/de/trial/DRKS00025831 ).

["Radical" versus "functional" surgery of the paranasal sinuses-A contradiction?] / "Radikale" vs. "funktionelle" Chirurgie der Nasennebenhöhlen ­ ein Widerspruch?

BACKGROUND AND OBJECTIVE: The terms "functional" and "radical" paranasal sinus surgery were often considered to be different operations which were mutually exclusive. This overview aims to look at the basics of these terms and surgical procedures and to work out the resulting surgical concepts for clinically relevant indications. MATERIAL AND METHODS: Selective literature analysis using the data base PubMed, corresponding textbooks and resulting secondary literature regarding functional and radical or extended paranasal sinus surgery. Similarly, the current literature regarding clinically relevant indications for sinus surgery were analyzed. RESULTS AND CONCLUSION: Modern pathophysiological knowledge, anatomically and pathophysiologically substantiated endoscopic surgical procedures and the usage of up to date technical possibilities have resulted in concepts which combine functional and so-called radical or extended surgery of the paranasal sinuses that complement each other and sometimes even overlap. The preoperative diagnosis and definition of underlying diseases are decisive and should be as precise as possible, as the extent and surgical details mainly depend on them: a sole creation of free drainage pathways, an additional creation of anatomical access for subsequent topical treatment or a complete (radical) removal of a pathological process.

[Fundamentals and practice of the application of nasal packing in sinonasal surgery]. / Grundlagen und Praxis der Anwendung von Nasentamponaden in der endonasalen Chirurgie.

BACKGROUND AND OBJECTIVES: This paper presents an overview on nasal packing materials which are available in Germany. The current literature is analyzed whether there are robust criteria regarding use nasal packing after sinonasal surgery, whether there are fundamental and proven advantages or disadvantages of products, and what this means in clinical practice. MATERIALS AND METHODS: Selective literature analysis using the PubMed database (key words "nasal packing", "nasal tamponade", "nasal surgery", "sinonasal surgery", or "sinus surgery"), corresponding text books and resulting secondary literature. RESULTS AND CONCLUSIONS: Because of systematic methodological shortcomings, the literature does not help in the decision-making about which nasal packing should be used after which kind of sinonasal surgery. In fact, individual approaches for the many different clinical scenarios are recommended. In principle, nasal packing aims in hemostasis, should promote wound healing, and should not result in secondary morbidity. Nasal packing materials should be smooth (non-absorbable materials), inert (absorbable materials), and should not exert excessive pressure. Using non-absorbable packing entails the risk of potentially lethal aspiration and ingestion. For safety reasons inpatient control is recommended as long as this packing is in situ. With other, uncritical packing materials and in patients with special conditions, outpatient control could be justified.

[Online survey to determine realistic success rates and trends in surgical septal perforation repair]. / Online-Befragung: realistische Erfolgsquoten und Trends beim operativen Septumperforationsverschluss.

OBJECTIVE: High success rates (SR) for surgical septal perforation repair (SPR) of over 90 % are reported in the literature. We think that realistic SR are significantly lower and wanted to confirm this thesis with the help of a survey among ear, nose, throat ENT specialists from Germany. Surgical trends were also queried. MATERIAL AND METHODS: An anonymous online survey among ENT specialists in Germany was conducted. 356 doctors participated. The collected SR were statistically evaluated, and the operative trends were analysed. It applies a significance level α = 0.05. The SR were collected for 3 different size categories (<1 cm, 1-2 cm, >2 cm). RESULTS: The SR for SPR <1 cm (median 79 %) was higher than that for 1-2 cm (60 %) and >2 cm (40 %). Surgeons estimated SR significantly higher (90 %, 75 %, 50 %; p-value <0.001 each) than non-surgeons (80 %, 50 %, 25 %). Hospital-based physicians (90 %, 70 %, 50 %) reported significantly higher SR than ambulatory physicians (80 %, 50 %, 30 %, p-value <0.001 each). No linear relationship was found between the total number of SPR performed and SR (r <1cm = 0.16, r1-2cm = 0.18, r >2cm = 0.19). Most SPR were performed with the bridge flap technique (73 %), a closed surgical approach (85 %), an interposition graft (74 %) and postoperative splinting (94 %). CONCLUSIONS: The subjective SR suggest that the SR of SPR is lower than described in the literature. This may be due to short follow-up times, small patient populations and a retrospective design of existing studies. The variety of surgical possibilities confirms the complexity of SPR. Optimising the design of future studies could help to collect realistic SR.

Decompression alone versus decompression with fusion in patients with lumbar spinal stenosis with degenerative spondylolisthesis: a systematic review and meta-analysis.

INTRODUCTION: Surgical decompression is standard care in the treatment of degenerative spondylolisthesis in patients with symptomatic lumbar spinal stenosis, but there remains controversy over the benefits of adding fusion. The persistent lack of consensus on this matter and the availability of new data warrants a contemporary systematic review and meta-analysis of the literature. METHODS: Multiple online databases were systematically searched up to October 2022 for randomized controlled trials (RCTs) and prospective studies comparing outcomes of decompression alone versus decompression with fusion for lumbar spinal stenosis in patients with degenerative spondylolisthesis. Primary outcome was the Oswestry Disability Index. Secondary outcomes included leg and back pain, surgical outcomes, and radiological outcomes. Pooled effect estimates were calculated and presented as mean differences (MD) with their 95% confidence intervals (CI) at two-year follow-up. RESULTS: Of the identified 2403 studies, eventually five RCTs and two prospective studies were included. Overall, most studies had a low or unclear risk of selection bias and most studies were focused on low grade degenerative spondylolisthesis. All patient-reported outcomes showed low statistical heterogeneity. Overall, there was high-quality evidence suggesting no difference in functionality at two years of follow-up (MD - 0.31, 95% CI - 3.81 to 3.19). Furthermore, there was high-quality evidence of no difference in leg pain (MD - 1.79, 95% CI - 5.08 to 1.50) or back pain (MD - 2.54, 95% CI - 6.76 to 1.67) between patients undergoing decompression vs. decompression with fusion. Pooled surgical outcomes showed less blood loss after decompression only, shorter length of hospital stay, and a similar reoperation rate compared to decompression with fusion. CONCLUSION: Based on the current literature, there is high-quality evidence of no difference in functionality after decompression alone compared to decompression with fusion in patients with degenerative lumbar spondylolisthesis at 2 years of follow-up. Further studies should focus on long-term comparative outcomes, health economic evaluations, and identifying those patients that may benefit more from decompression with fusion instead of decompression alone. This review was registered at Prospero (CRD42021291603).

Telemedical Support Using Smartphones for Spine Surgery in Low- and Middle-Income Countries.

Objective: Low- and middle-income countries (LMICs) face many challenges compared to industrialized nations, most notably in regard to the health care system. Patients often have to travel long distances to receive medical care with few reliable transportation mechanisms. In time-critical emergencies, this is a significant disadvantage. One specialty that is particularly affected by this is spine surgery. Within this field, traumatic injuries and acutely compressive pathologies are often time-critical. Increasing global networking capabilities through internet access offers the possibility for telemedical support in remote regions. Recently, high-performance cameras and processors became available in commercially available smartphones. Due to their wide availability and ease of use, this could provide a unique opportunity to offer telemedical support in LMICs. Methods: We conducted a feasibility study with a neurosurgical institution in east Africa. To ensure telemedical support, a commercially available smartphone was selected as the experimental hardware. Preoperatively, resolution, contrast, brightness, and color reproduction were assessed under theoretical conditions using a test chart. Intraoperatively, the image quality was assessed under different conditions. In the first step, the instrumentation table was displayed, and the mentor surgeon marked an instrument that the mentee surgeon should recognize correctly. In the next evaluation step, the surgical field was shown on film and the mentor surgeon marked an anatomical structure, and in the last evaluation step, the screen of the X-ray machine was captured, and the mentor surgeon again marked an anatomical structure. Subjective image quality was rated by two independent reviewers using the similar modified Likert scale as before on a scale of 1-5, with 1 indicating inadequate quality and 5 indicating excellent quality. Results: The image quality during the video calls was rated as sufficient overall. When evaluating the test charts, a quality of 97% ± 5 on average was found for the chart with the white background and a quality of 84% ± 5 on average for the chart with the black background. The color reproduction, the contrast, and the reproduction of brightness were rated excellent. Intraoperatively, the visualization of the instrument table was also rated excellent. Visualization of the operative site was rated 1.5 ± 0.5 on average and it was not possible to recognize relevant anatomical structures with the required confidence for surgical procedures. Image quality of the X-ray screen was rated 1.5 ± 0.9 on average. Conclusion: Current generation smartphones have high imaging performance, high computing power, and excellent connectivity. However, relevant anatomical structures during spine surgery procedures and on the X-ray screen in the operating room could not be identified with reliability to provide adequate surgical support. Nevertheless, our study showed the potential in smartphones supporting surgical procedures in LMICs, which could be helpful in other surgical fields.

[Telemedicine in Otorhinolaryngology and Head and Neck Surgery - An universal remedy?] / Telemedizin in der HNO-Heilkunde ­ wirklich ein Allheilmittel?

Digitalization in healthcare has gained considerable importance in recent years and especially during the Covid19 pandemic. The pandemic has undeniably severely limited human interactions. In light of the risk of infection, and also in light of the decreasing number of physician consultations by patients due to fear of infection, the medical community has had to seek new platforms for physician-patient interaction and -communication and achieved these goals predominantly by accelerating the development of digitization processes and telemedicine. In otolaryngology, the term telemedicine usually refers to video consultation (VS) or teleconsultations. In principle, ENT physicians belong to the group of specialists who are allowed to perform and invoice video consultations. Data protection and legal aspects pose challenges with regard to offering telemedical services. From an ethical point of view, any telemedical consultation would also have to be preceded by a mandatory explanation of the risks and disadvantages of using these procedures, and the basis for liability would also have to be clarified here in principle. Telemedicine will also have to assert itself in view of the evidence. Thus, at least from the medical university side, accompanying studies should be initiated when new telemedical procedures are offered, in order to evaluate the corresponding advantages and disadvantages on the basis of evidence. In terms of professional policy, care should always be taken to ensure that telemedicine is only offered by players in the healthcare sector who can also guarantee personal treatment of the patient assessed by telemedicine.

Feasibility of smart glasses in supporting spinal surgical procedures in low- and middle-income countries: experiences from East Africa.

OBJECTIVE: Telemedicine technology has been developed to allow surgeons in countries with limited resources to access expert technical guidance during surgical procedures. The authors report their initial experience using state-of-the-art wearable smart glasses with wireless capability to transmit intraoperative video content during spine surgery from sub-Saharan Africa to experts in the US. METHODS: A novel smart glasses system with integrated camera and microphone was worn by a spine surgeon in Dar es Salaam, Tanzania, during 3 scoliosis correction surgeries. The images were transmitted wirelessly through a compatible software system to a computer viewed by a group of fellowship-trained spine surgeons in New York City. Visual clarity was determined using a modified Snellen chart, and a percentage score was determined on the smallest line that could be read from the 8-line chart on white and black backgrounds. A 1- to 5-point scale (from 1 = unrecognizable to 5 = optimal clarity) was used to score other visual metrics assessed using a color test card including hue, contrast, and brightness. The same scoring system was used by the group to reach a consensus on visual quality of 3 intraoperative points including instruments, radiographs (ability to see pedicle screws relative to bony anatomy), and intraoperative surgical field (ability to identify bony landmarks such as transverse processes, pedicle screw starting point, laminar edge). RESULTS: All surgeries accomplished the defined goals safely with no intraoperative complications. The average download and upload connection speeds achieved in Dar es Salaam were 45.21 and 58.89 Mbps, respectively. Visual clarity with the modified white and black Snellen chart was 70.8% and 62.5%, respectively. The average scores for hue, contrast, and brightness were 2.67, 3.33, and 2.67, respectively. Visualization quality of instruments, radiographs, and intraoperative surgical field were 3.67, 1, and 1, respectively. CONCLUSIONS: Application of smart glasses for telemedicine offers a promising tool for surgical education and remote training, especially in low- and middle-income countries. However, this study highlights some limitations of this technology, including optical resolution, intraoperative lighting, and internet connection challenges. With continued collaboration between clinicians and industry, future iterations of smart glasses technology will need to address these issues to stimulate robust clinical utilization.

[Adaption of the "Empty Nose 6 Item Questionnaire" (ENS6Q) into German language]. / Erstellung einer deutschen Version des "Empty Nose Syndrome 6 Item Questionnaire" (ENS6Q).

OBJECTIVE: The English "Empty-Nose-6-Item-Questionnaire" (ENS6Q) is a validated tool to assess subjective and disease-specific complaints of patients suffering from empty nose syndrome. The aim of this study was to create a validated German adapted version (GAV) of the ENS6Q. MATERIAL AND METHODS: The ENS6Q was translated into German language using a multistage process. Subsequently the translated questionnaire was completed twice by a group of patients suffering from empty nose syndrome (n = 36), a healthy control group (n = 77) and a group of patients with a symptomatic pathology of the nasal septum (n = 78). Additionally, the NOSE© questionnaire was completed twice by all groups. The ENS6Q was then examined regarding internal consistency, test-retest reliability, discriminant validity, sensitivity and specificity. RESULTS: The ENS6Q-GAV shows high internal consistency with Cronbachs α = 0,760 and α = 0,795. It also shows good test-retest reliability with an interclass correlation coefficient of 0,947 [0,930 - 0,961]. The ENS6Q-GAV discriminated significantly between empty nose syndrome patients and the control group. The receiver-operating characteristics curve showed a sensitivity of 83,3 % and a specificity of 88,3 % using a cut-off point of 8,5. The area-under-the-curve threshold score was 0,914 ± 0,029 [0,856 - 0,971]. CONCLUSIONS: The ENS6Q-GAV is the first validated disease-specific questionnaire in German to help identify patients suspected of developing ENS more reliably.

3D endoscopy shows enhanced anatomical details and depth perception vs 2D: a multicentre study.

PURPOSE: The current standard endoscopic technique is a high resolution visualisation up to Full HD and even 4 K. A recent development are 3D endoscopes providing a 3-dimensional picture, which supposedly gives additional information of depth, anatomical details and orientation in the surgical field. Since the 3D-endoscopic technique is new, little scientific evidence is known whether the new technique provides advantages for the surgeon compared to the 2D-endoscopic standard technique in FESS. This study compares the standard 2D-endoscopic surgical technique with the new commercially available 3D-endoscopic technique. METHODS: The prospective randomized interventional multicenter study included a total of 80 referred patients with chronic rhinosinusitis with and without polyps without prior surgery. A bilateral FESS procedure was performed, one side with the 2D-endoscopic technique, the other side with the 3D-endoscopic technique. The time of duration was measured. Additionally, a questionnaire containing 20 items was completed by 4 different surgeons judging subjective impression of visualisation and handling. RESULTS: 2D imaging was superior to 3D apart from "recognition of details", "depth perception" and "3D effect". For usability properties 2D was superior to 3D apart from "weight of endoscopes". Mean duration for surgery was 26.1 min for 2D and 27.4 min. for 3D without statistical significance (P = 0.219). CONCLUSION: Three-dimensional endoscopy features improved depth perception and recognition of anatomic details but worse overall picture quality. It is useful for teaching purposes, yet 2D techniques provide a better outcome in terms of feasibility for routine endoscopic approaches.

Rare Diseases of the Nose, the Paranasal Sinuses, and the Anterior Skull Base. / Seltene Erkrankungen der Nase, der Nasennebenhöhlen und der vorderen Schädelbasis.

Due to their low incidence and thus resulting limited diagnostic criteria as well as therapeutic options, rare diseases of the nose, the paranasal sinuses, and the anterior skull base are a significant challenge. The value as of which a disease has to be considered as rare amounts to a maximum of 5 patients per 10 000 people. Within these diseases, however, there are extreme differences. Some rare or orphan diseases like for example the inverted papilloma belong to regularly diagnosed and treated diseases of larger departments of oto-rhino-laryngology whereas other rare diseases and malformations have only been described in less than 100 case reports worldwide. This fact emphasizes the necessity of bundling the available experience of diagnostics and therapy. The present article gives an overview about rare diseases of the nose, the paranasal sinuses, and the anterior skull base from the field of diseases/syndromes of the olfactory system, malformations of the nose and paranasal sinuses, ventilation and functional disorders as well as benign and malignant tumors. The classification and data on diagnostic and therapeutic options were established based on the current literature.

[Closure of Nasal Septal Perforation]. / Der chirurgische Septumperforationsverschluss.

Symptomatic nasal septal perforations can lead to a substantial restriction in the quality of life of patients and present a distinct surgical challenge for the otolaryngologist/head and neck surgeon. Symptomatic patients complain about nasal crusting, recurrent nosebleeds and nasal obstruction. The so called 4 bridge-flap technique including the interposition of autologous ear cartilage presents an established surgical method for closure of a septal perforation. In the present article, the surgical procedure is described in detail.

[Importance of machine blood count in the diagnosis of infectious mononucleosis by EBV]. / Stellenwert des maschinellen Blutbildes bei der Diagnose der infektiösen Mononukleose durch EBV.

INTRODUCTION: EBV serology is recommended for serological diagnosis of mononucleosis. As results of an automated differential blood count is available more quickly, possible differences between an EBV primary infection and a bacterial tonsillitis were investigated. METHODS: A retrospective evaluation of absolute and relative lymphocyte and monocyte counts of n = 140 patients > 16 years from 01/2008 to 01/2019 (mean age 21.4 years, 51 % ♀, 49 % ♂) with suspected EBV infection was performed. The groups of a serologically confirmed or excluded EBV infection were compared. RESULTS: An automated differential blood count was available in n = 42 patients with primary EBV infection. Average lymphocyte count was 5.5 ±â€Š2.6 giga/l. Patients with acute bacterial tonsillitis (n = 36) had significantly lower values with 1.6 ±â€Š1.3 giga/l, p < 0.05. Equal results were found in relative lymphocyte counts (47.4 ±â€Š17.9 vs. 12.8 ±â€Š9.1 %, p < 0.05). For monocyte counts, neither absolute (1.2 ±â€Š0.8 vs. 1.2 ±â€Š0.6 giga/l, p = 0.617) nor relative (8.8 ±â€Š3.6 vs. 9.8 ±â€Š5.2 %, p = 0.746) monocyte counts showed significant differences. CONCLUSION: Increased lymphocyte counts in an automated differential blood count can be a first indication of primary EBV infection. Perhaps up to 30 % morphologically altered lymphocytes are increasingly counted correctly with modern hematology analyzers and no longer counted as monocytes. These results could be used to make decisions about further diagnosis (abdominal ultrasonography, ECG) and antibiotic therapy before results of EBV serology are available.

Modified less invasive anterior subcutaneous fixator for unstable Tile-C-pelvic ring fractures: a biomechanical study.

BACKGROUND: Operative procedures for unstable pelvic ring fractures remain controversially discussed. Minimally invasive treatment options for pelvic ring fractures have several benefits for the patient. But they can also provide disadvantages. Anterior subcutaneous pelvic fixation (INFIX) has shown promising biomechanical results in pelvic ring fractures, but there is a high complication rate of nerve injuries. An additional screw to the INFIX seems to be more stable. The aim of this study is to compare biomechanical stability of a new modified unilateral INFIX fixing the unilateral injured pelvic ring with the standard INFIX. METHODS: 24 composite synthetic full pelvises were used in this study. 4 groups each with a number of six pelvic specimens were randomly assigned. A C1.3-type pelvic fracture was made with an osteotomy of the sacrum and an osteotomy of the anterior pelvic ring. Fracture fixation was performed within the four groups: (1) unilateral INFIX, (2) "extended" unilateral INFIX + additional pubic ramus pedicle screw, (3) bilateral INFIX, (4) "extended" bilateral INFIX + additional pubic ramus pedicle screw. All specimens were cyclic loaded with 200 N until maximum of 300 N. Distance/dislocation of the fracture fragments were detected with 3D-ultrasound measuring system. Stiffness was calculated. RESULTS: Extended unilateral INFIX showed the lowest mean dislocation. Lowest rotational stability was displayed by the standard bilateral INFIX. A significant difference (P = 0.04) was shown between the extended unilateral INFIX and the "standard" bilateral INFIX in terms of rotational stability. Extended unilateral INFIX showed significantly improved stability of anterior fracture dislocation (P = 0.01) and unilateral INFIX showed the highest rotational stiffness. Anterior fixation stiffness of the unilateral INFIX was significantly improved using an additional symphysis/pubic ramus screw (P = 0.002). CONCLUSION: Extended unilateral INFIX (+ additional pubic ramus pedicle screw) is a feasible minimally invasive treatment for anterior pelvic ring fractures. Higher stability and lower probability of bilateral nerve damage is provided by the extended unilateral INFIX compared to the standard bilateral INFIX.

Intraoperative MRI in transsphenoidal resection of invasive pituitary macroadenomas.

The use of intraoperative MRI (iMRI) increases extent of resection in transsphenoidal pituitary surgery. Microsurgical and endoscopic techniques have been established as equal and standard surgical methods. The object of the current study was to evaluate the additional value of iMRI for resection of invasive pituitary adenomas. We conducted a retrospective monocenter study of all consecutive patients treated with invasive pituitary adenomas graded as Knosp III-IV at our department after the introduction of iMRI in 2008. Out of 315 transsphenoidal surgeries for pituitary adenomas, 111 met the criteria for analysis. Patients treated with endoscopic or microsurgical technique were included. iMRI was performed at surgeons' discretion, when maximal safe resection was assumed. Detailed volumetric tumor analysis using semiautomatic segmentation software (Brainlab Elements) before surgery, during surgery, and after surgery was performed. Additionally, demographic data, additional resection, endocrinological outcome as well as complications were evaluated. Postoperative tumor volume as measured in the follow-up MRI 3 months after surgery was significantly lower compared with intraoperative tumor volume (p < 0.001). The difference was statistically significant for both surgical techniques (p < 0.001). No significant difference was found between both techniques in intraoperative and postoperative tumor volume (p = 0.395 and p = 0.329 respectively). Additional tumor resection was performed in 56 cases (50.5%). We found no significant difference between microsurgical and endoscopic techniques regarding additional resection after iMRI (p = 0.512). New diagnosed permanent diabetes insipidus was found in 10 patients (10.5%, 10/95). New hypopituitarism was seen in 22.1% (21/95) cases and according to multivariate logistic regression was significantly associated with microsurgical technique (p = 0.035). Visual improvement was achieved in 76.8% (N = 53/69, p < 0.001) of patients with visual impairment before surgery. Revision surgery as the consequence of cerebrospinal fistula was performed in eight cases (7.2%). Meningitis was documented in three patients (2.7%). One patient died as a consequence of intraoperative vascular injury. Intraoperative MRI after maximal safe resection significantly improves the overall extent of resection in invasive pituitary adenomas independent of the surgical technique employed. Simultaneously, iMRI-assisted transsphenoidal surgery results in excellent visual recovery with low-risk profile for surgical complications for both endoscopic as well as microsurgical technique. Endoscopic technique might be related to the lower incidence of new hypopituitarism after surgery.

Incidence of anatomical variations according to the International Frontal Sinus Anatomy Classification (IFAC) and their coincidence with radiological sings of opacification.

BACKGROUND: The endonasal access to the frontal recess and sinus may be complicated by a variety of anatomical variations. Previous classifications of these variants were characterized by proper names or position information without anatomical reference. The IFAC is intended to simplify the classification of anatomical variations of the frontoethmoidal complex. The aim of this study was to analyse a representative number of sinus CT scans to assess the incidence of anatomical variations according to the IFAC and to compare the results with previous classifications. In addition, the coincidence of complex anatomical variations and radiological sings of opacification was investigated. METHODOLOGY/PRINCIPAL: Two hundred and forty-nine sinus CT scans were analysed in multiplanar reconstructions. Exclusion criteria were previous operations on the paranasal sinuses, malignant diseases, and an insufficient image quality. All anatomical variants were analysed according to the IFAC criteria. In addition, the coincidence of radiological sings of opacification and the presence of anatomical variations of the frontal recess and sinus were investigated. RESULTS: The analysis revealed Agger nasi cells in 95% of the CT scans. Supra agger cells (SACs) were detected in 49% and Supra agger frontal cells (SAFCs) in 25% of the data sets. Suprabulla cells (SBCs) were detected in 89% and Supra bulla frontal cells (SBFCs) in 27% of the scans. Supraorbital ethmoid cells (SECs) were detectable in 9% and interfrontal septal cells in 28% of the scans. Despite a partially strong narrowing of the frontal recess, no increased occurrence of radiological sings of opacification could be detected (p > 0.05). CONCLUSIONS: Anatomical variations in the frontoethmoidal area are very common. According to the IFAC criteria, in 43% of the patients, cells could be detected with pneumatization to or into the frontal sinus. The IFAC is structured more clearly compared to previous classifications due to the anatomical aspect. It represents the most consistent classification regarding surgical planning. Further studies will demonstrate the scientific and clinical value of this classification.

[Symptoms and parental expectation in adenoidectomy and adenotonsillotomy in preschool children]. / Hauptsymptome und Elternerwartung bei Adenotomie und Adenotonsillotomie im Vorschulalter.

OBJECTIVE: In this study, symptoms associated with adenoids and hyperplasic palatine tonsils and parental expectation of surgical outcome were recorded, to provide realistic parental information prior to adenoidectomy (AT) ± tonsillotomy (ATT). MATERIAL AND METHODS: In total n = 111 children (3-6 years, ♂ 65 % ♀ 35 %) were recruited, who received AT (66 %) or ATT (34 %) at ENT University Hospital Ulm. By questionnaire-based survey, the most common symptoms and the main reason for the operation were reported from parent's perspective (operation day, follow-up: 3.5 months). Results were visualized in bar charts for total collective and AT and ATT surgical groups (significance level α = 5 %). RESULTS: Most commonly, parents observed signs of respiratory problems (mouth breathing 87 %, nasal obstruction 86 %, snoring 78 %), hearing loss (68 %) and infection of upper airways (66 %). Nasal obstruction (77.5 %) and hearing loss (53.2 %) were the main reasons for operation. In children with pharyngeal tonsil hyperplasia only, hearing problems dominated, while in additional tonsillotomy, nocturnal apneas were the most frequently reported reason for surgery. For all symptoms, a significant postoperatively improvement was achieved. CONCLUSIONS: With a differentiated indication for surgery, it is possible to inform the parents about a very good and realistic and effective reduction of symptom after AT and ATT.

[The KINDL questionnaire for assessment of general quality of life in adenotonsillar hyperplasia]. / Der KINDL-Fragebogen zur Erfassung der allgemeinen Lebensqualität bei adenotonsillärer Hyperplasie.

BACKGROUND: There are few systematic studies on the general quality of life of children before and after adenoidectomy and adenotonsillotomy, although interventions on adenoids and tonsils are the most frequent operations in childhood in Germany. For this reason, the established KINDL questionnaire was used to assess the quality of life of children for the first time. METHODS: Study participants (n = 111) and a waiting design control group (n = 35) were recruited consecutively from children (3-6 years) receiving adenoidectomy (66 %) or adenotonsillotomy (34 %). The Kiddy-KINDL® questionnaire was answered by parents on the day of surgery and 3.5 months postoperatively. Parents of the control group were interviewed, when the date of operation was scheduled and on the day of operation. RESULTS: Total scale score of the Kiddy-KINDL of max. 100 points improved slightly in the intervention group from preoperatively 75.9 ±â€Š10.8 (95 %-KI [73.8-77.9]) to postoperatively 77.2 ±â€Š9.2 points (95 %-KI [75.1-79.0]; p = 0.365). Also in the comparison group there was no significant change over time (77.9 ±â€Š9.7; 95 % CI [74.1-81.7] vs. 77.3 ±â€Š11.3; 95 % CI [72.8-81.8]; p = 0.949) or compared to the preoperative score of the intervention group (p = 0.894). The subscales scores for "physical well-being" (p < 0.01), "school" (p = 0.034) and "parents" (p < 0.01) showed significant improvements for the intervention group. Children with additional tonsillotomy also showed a significant postoperative increase of the total scale score (p = 0.049). CONCLUSION: The version of the Kiddy-KINDL we used is therefore not fully suitable for recording the general QOL in adenotonsillar hyperplasia, since an improvement in QOL could only be recorded in subscales. However, since tonsillotomy in particular seems to have a relevant influence on QOL, it should be performed in children with significant hyperplasia.

[Analysis of facial asymmetry in patients with crooked noses]. / Analyse von Gesichtsasymmetrien bei Patienten mit Schiefnasen.

BACKGROUND: Surgical management of crooked nose is challenging even for experienced rhino surgeons, although numerous techniques for correction have been described. Not infrequently, there is a facial asymmetry in addition to the crooked nose influencing the aesthetic results of the operation. Therefore, the purpose of this study was to determine how often there is an asymmetry of the face in addition to a crooked nose. MATERIAL AND METHODS: Retrospectively the data of 607 patients with a crooked nose (304 women, 303 men, mean age 30 years) were evaluated. The preoperative photos of the face were anthrometrically assessed based on angle measurements. RESULTS: 382 of the 607 patients had a c-shaped (63 %) and 225 an i-shaped (37 %) crooked nose. More than three-quarters of the patients had facial asymmetry in respect to the connecting line of the pupils and nasal base line. 49 % of patients reported a history of nasal trauma, but this had no relevant influence on the frequency of facial asymmetry. CONCLUSIONS: Pre-existing facial asymmetry is very common in patients with crooked nose and can significantly affect the aesthetic outcome of nasal surgery. This should be addressed as part of the informed consent. In particular, it should be mentioned that the surgical outcome can remain below the patient's aesthetic expectations. Not rarely, a revision surgery may be necessary.

[Adaptation of the "Nasal Obstruction Symptom Evaluation" (NOSE©) questionnaire in the German language]. / Erstellung einer deutschen Version des "Nasal Obstruction Symptom Evaluation" Fragebogens (NOSE©).

OBJECTIVE: The standardized and validated English NOSE© questionnaire is used to assess subjective complaints of nasal obstruction. The aim of our study was to create and validate a German version of the NOSE© questionnaire. MATERIAL AND METHODS: The original questionnaire was translated into German in multiple steps. The English back translation was sufficiently similar to the original questionnaire. Next, the translated questionnaire was completed twice each by a group of patients with symptoms of nasal obstruction (n = 76) and a group of nose healthy test persons (n = 104). Subsequently, the questionnaire was tested for internal consistency, test-retest reliability, construct validity, discriminant validity and sensitivity to change. Additionally, it was examined whether the rhinomanometric results of the patient group correlated with their questionnaire scores. RESULTS: The created German NOSE questionnaire had high internal consistency with an average result of Cronbach's α ≥ 0.8. The test-retest reliability was also satisfactory with Goodman-Kruskal-γ = 0.826. The discriminant validity showed significant differences between the patient and control group. Furthermore, sensitivity to change was high. The patients' rhinomanometric results before operation did not correlate with the corresponding NOSE questionnaire Scores. CONCLUSIONS: The study showed that the created German Version of the NOSE© questionnaire (NOSE GAV) is a valid method for assessment of subjective nasal obstruction. It can be used throughout German-speaking areas without restriction.