Swallowed denture stuck in the proximal esophagus.

A 72-year-old male with dementia and Parkinson's disease presented at the otorhinolaryngology outpatient clinic with acute dysphagia. A chest x­ray showed a dental prosthesis in the upper esophagus, which was subsequently extracted via rigid esophagoscopy. Due to suspected esophageal perforation on postoperative CT, a cervical approach to the esophagus and flexible esophagoscopy were used, but no evidence of perforation could be identified. This case highlights challenges in managing high-risk esophageal foreign bodies in the upper esophagus, emphasizing the need for careful assessment and a multidisciplinary approach.

Anatomic-Topographic Investigation of the Branches of the Dorsal Ramus of Thoracic Spinal Nerves.

INTRODUCTION: Percutaneous radiofrequency facet denervation (PRFD) by thermocoagulation is a useful treatment for nonspecific thoracic pain syndrome. To guarantee that maximal thermal lesion is applied to the nerve, it is essential to have precise knowledge of the topography of the thoracic dorsal branches of the spinal nerves. This special anatomy was investigated, and the results were compared with the existing technique for PRFD, where the active needle tip is placed in the junction of the superior articular process and the transverse process. METHODS: Twenty thoracic spines of cadavers (10 females and 10 males) embalmed according to Thiel's method were bilaterally dissected. After careful removal of skin and subcutaneous fat tissue, the lateral and medial branches were traced centrally. In addition, the articular branch to the thoracic facet joint was traced peripherally. The distance of the medial branch to the inferior articular process at the level of the nerve passing the superior costotransverse ligament was measured. RESULTS: The dorsal branch bifurcates into lateral and medial branches medial to the superior costotransverse ligament. The medial branch runs laterally first to pass in between two parts of the intertransverse ligament running dorsally and to turn medially superficial to this ligament. The zygapophysial branch always originated from the medial branch passing the inferior articular process laterally by running caudally to turn medially and send branches to the capsule of the zygapophyseal joint. The distance of the medial branch lateral to the inferior articular process was constantly 3 mm. CONCLUSIONS: The current technique of PRFD at the thoracic spine targets the medial branch distal to the separation of the articular branch, rendering the lesion ineffective at denervating the zygapophyseal joint. For selective thermocoagulation of the articular branches of the thoracic zygapophyseal joint, a new technique should be developed. We propose an anatomically informed needle position that can now be confirmed clinically.

Anatomical Topographical Investigation of the Medial Branch of the Dorsal Thoracic Branch of the Spinal Nerve in the Segments T10-T12.

INTRODUCTION: The zygapophyseal joints represent one possible cause for back pain. Therefore, many interventions are targeting the denervation of the facet joints. The aim of this study is to describe the course of the medial branch of the dorsal branch of the spinal nerve and its articular branches to the zygapophyseal joints in the segments T10-T12. METHODS: The medial branches in the thoracic segments T10-T12 were dissected in 20 Thiel embalmed cadavers. An Eschenbach magnifying glass (4.0× magnification) was used during dissection preserving the articular branches. The topography and the branching pattern of the medial branches was observed. RESULTS: The course of the nerves in the segments T10-T12 differed from each other because of the different osseous anatomy of each segment. The medial branch at the segment T10 crossed the tip of the transverse process in 28 of the 40 hemivertebral specimens. In the remaining cases it passed superior to the transverse process. At T11 the medial branch ran constantly through an osteofibrous canal. At the segment T12 the medial branches showed a similar course to the medial branches in the lumbar region. In many cases two articular branches, which arose from the medial branch were identified. CONCLUSIONS: The results of this study show a considerable anatomic variety at the segment T10. It also demonstrates that the transverse process is an important landmark to encounter the medial branch. Furthermore, the possibility of a double innervation of the facet joints should always be considered.

Comparison of two different intratympanic corticosteroid injection protocols as salvage treatments for idiopathic sudden sensorineural hearing loss.

PURPOSE: We aimed to investigate the effect of interval length and total count of intratympanic steroid (ITS) injections in salvage treatment of patients with idiopathic sudden sensorineural hearing loss (ISSNHL). METHODS: This retrospective case-control study included 64 patients with ISSNHL, who were treated with ITS injections as salvage therapy at a tertiary referral centre. From September 2019 to December 2020, 32 patients received up to four injections every 2-4 days (revised-protocol group). These patients were 1:1 matched to patients, who received up to three injections at 1-week intervals between January 2014 and August 2019 (initial-protocol group). Hearing outcomes of the two groups were compared. RESULTS: Both ITS salvage treatment protocols resulted in a statistically significant hearing improvement (p < 0.05). The initial-protocol declined hearing thresholds by 12 ± 11.7 dB (p < 0.001, d = 1, P = 99%). Mean hearing function was improved by 13.4 ± 19.1 dB in the revised-protocol group [p < 0.001, d = 0.7, P = 98%]. A clinically significant hearing improvement (> 10 dB) was seen in 18 patients (58.1%) in the initial-protocol group and in 14 patients (41.9%) in the revised-protocol group. A comparison of the hearing outcomes between protocol groups revealed no statistically significant differences (p > 0.05). CONCLUSION: These results indicate that a shorter injection interval does not lead to better hearing outcomes in ITS salvage treatment for ISSNHL. Moreover, fewer ITS injections may reduce costs, physical/mental stress of the patients and lower the risk of persistent tympanic perforations.

Preservation of nasal turbinates in endoscopic, anterior skull base surgery-yes, we can!

OBJECTIVE: To evaluate the frequency, type and indications of nasal turbinate (NT) resection during endoscopic, anterior skull base surgery and to analyze factors that may have an impact on the need of NT removal. METHODS: In this retrospective cohort study, 306 subjects (150 males and 156 females, mean age 55.4 ± 15.3 years) who underwent multidisciplinary, transnasal, endoscopic tumor surgery of the anterior skull base using 4-handed techniques between 2011 and 2019 at the Department of Otorhinolaryngology, Medical University of Graz, were included. RESULTS: In the majority of interventions (n = 281/306; 91.8%), all NT were preserved. Significant factors influencing the need of NT resections turned out to be type of endoscopic approach (p < 0.001; V = 0.304), sagittal (p = 0.003; d = 0.481) and transversal (p = 0.017; d = 0.533) tumor diameter, tumor type (p < 0.001; V = 0.355) and tumor location (p < 0.001; V = 0.324). CONCLUSIONS: NT can be preserved in the majority of patients undergoing tumor resection in anterior, transnasal, skullbase surgery and routine resection of NT should be avoided. Variables that have an impact on the need of NT resections are types of endoscopic approaches, sagittal and transversal tumor extension and tumor type. These factors should be considered in planning of surgery and preoperative information of patients.

Terminology of the branches of the lateral circumflex femoral artery: Who is Who?

The anterolateral thigh flap and the tensor fasciae latae flap are supplied by the lateral circumflex femoral artery (LCFA). Different branching patterns of the LCFA have been described, leading to confusion, discrepancies and difficulties in clinical and cadaveric study comparisons. The aim of this study was to evaluate the branching patterns of the LCFA in dissected lower limbs and propose a simplified nomenclature. One hundred and two lower limbs fixed with Thiel's method were investigated. Meticulous dissection was performed, and the branching pattern of the arteries was documented by illustration and photography. These were analysed and allocated to the currently existing terminologies regarding the numbers of the branches (Part 1), and these subgroups were evaluated according to the variability of the trunk formations (Part 2). In Part 1, four subgroups could be classified (A, B, C and D). Group A included a total number of three branches (n = 50), Group B included four (n = 41), Group C included five (n = 5) and Group D included only two branches (n = 6). Part 2 showed in total 11 different trunk variations. Group A had four trunk variations: A1 (n = 38), A2 (n = 5), A3 (n = 2) and A4 (n = 6); Group B also had four variations: B1 (n = 16), B2 (n = 18), B3 (n = 3) and B4 (n = 4); Group C displayed two variations: C1 (n = 1) and C2 (n = 4); and in Group D, there was only one variation observed D1 (n = 6). Branching patterns were highly variable and inconsistent in terms of the number of branches and trunk variations, which resulted in different possible and justified interpretations and classifications. A new terminology should be defined cooperatively among anatomists and clinicians that will be useful for everybody. We propose a terminology oriented to the associated muscles.

Intratympanic Triamcinolone Acetonide as a Salvage Treatment for Idiopathic Sudden Sensorineural Hearing Loss.

INTRODUCTION: Intratympanic steroid (ITS) injections represent an increasingly used salvage treatment option for patients with idiopathic sudden sensorineural hearing loss -(ISSHL) after systemic treatment. The most effective corticosteroid for this treatment modality still remains unclear. Triamcinolone acetonide has been used for ITS treatment in various clinical settings. However, there are limited clinical data of its usage in the therapeutic management of ISSHL. The aim of this study was to determine the efficacy of intratympanic triamcinolone acetonide injections as a salvage treatment for ISSHL. METHODS: We conducted a retrospective chart review on patients affected by ISSHL with insufficient hearing recovery after primary systemic corticosteroid therapy and who were treated with intratympanic triamcinolone acetonide as a salvage therapy between January 2014 and August 2019. The patients were divided into groups according to their degree of hearing recovery, and we evaluated potential predictors of hearing recovery. Audiometric results were then compared to historic studies using dexamethasone or methylprednisolone. RESULTS: One-hundred and fifty-two patients received up to 3 intratympanic injections with triamcinolone acetonide at 1-week intervals. The mean hearing improvement due to ITS salvage treatment was 15.9 ± 18.9 dB. Complete hearing recovery was noted in 15 patients (9.9%), while 73 patients (48%) obtained partial recovery, and 64 patients (42.1%) had no recovery. Primary systemic treatment delay, hearing improvement by primary systemic treatment, and severity of initial hearing loss were identified as significant predictors of hearing improvement. The first of the 3 injections resulted in the greatest hearing improvement. CONCLUSION: The use of triamcinolone acetonide in ITS salvage treatment resulted in similar hearing improvements as the use of the commonly used corticosteroids, namely, dexamethasone and methylprednisolone. Longer treatment delays, lower hearing improvement by primary systemic treatment, and higher initial hearing loss are associated with poorer prognoses of hearing recovery.

Volumetric Investigation of Sphenoid Sinus in an Elderly Population.

The aims of this study were to determine the sphenoid sinus volume in an Austrian population, evaluate the relationship between volume and different types of pneumatization and investigate possible age-related sphenoid sinus volume degeneration in the elderly. A total of 50 human cadaver including 25 male and 25 female samples (=100 sphenoid sinuses, age range 65-100, mean age 84.52 ±â€Š9.50) were selected to obtain volume and anatomical variants of pneumatization by using sphenoid sinus casts, made of quadrofunctional hydrophilic addition reaction silicone. The mean sphenoid sinus volume was 4.79 ±â€Š2.39 cm. Males showed statistically significant larger sinus volumes than females (P = 0.048). The volume differed statistically significant for the different types of pneumatization (P < 0.001). The combined type of sphenoid sinus pneumatization presented the largest volume with 7.20 cm, followed by lateral, clival, sphenoid body, presellar, and conchal sinus type with 5.72, 5.63, 4.25, 2.08, and 0.5 cm, respectively. No significant correlation between age and sphenoid sinus volume was found (P = 0.707). This study highlights the close relationship between volume and morphology of sphenoid sinus and confirms ethnic variability. Moreover, our data shows no age-related volume degeneration.

Scala vestibuli cochlear implant supported by 3D modeling of the inner ear.

Patients with scala tympani (ST) ossification present a distinct surgical challenge. Three-dimensional (3D) segmentation of the inner ear offers accurate identification of ossification and surgical planning of the cochleostomy to access the scala vestibuli. The scala vestibuli placement of cochlear implantation electrode is an alternate solution in these patients and is well supported by the literature.The present report describes a case of cochlear implantation in the scala vestibuli assisted by 3D segmentation of the cochlea for a patient with ossification in the ST and reviews the relevant literature. Clinical presentation of a 45-year-old Austrian female who was referred with a history of sudden sensorineural hearing loss 2 years ago in the right ear, confirmed by pure tone audiometry (PTA) and acoustically evoked auditory brainstem response (ABR). 3D segmentation of the inner ear identified the extent of ossification in the ST and assisted in the surgical planning of cochleostomy drilling anterior-superior to the round window to access the scala vestibuli for the electrode placement. Postoperative computed tomography (CT) to confirm the electrode placement in the scala vestibuli and PTA was performed to assess the hearing threshold following the cochlear implantation. Postoperative CT confirmed the full insertion of a flexible electrode. The hearing threshold measured by PTA was ≤ 40 dB across all frequencies tested. Review of the literature identified a total of 13 published reports on cochlear implantation electrode placement in scala vestibuli in cases with ossification in the ST.

Septoplasties are unlikely to cause postoperative numbness of the anterior palate.

BACKGROUND: Septoplasties and septorhinoplasties are very commonly performed surgical procedures in modern aesthetic and functional medicine. Throughout the surgery, close manipulation to the incisive nerves' course is being executed. This retrospective analysis followed up on potential sensitivity disorders of the anterior palate due to nerve damage. METHODS: This retrospective review of 2000 patients' charts, who had undergone the procedure of a septoplasty or septorhinoplasty between June 2013 and January 2019 was conducted at the Department of General Otorhinolaryngology, Medical University of Graz. Medical records of all included patients were reviewed with special attention to postoperative numbness of the anterior palate. RESULTS: Among the 2000 included patients, a septoplasty was performed in 48% (n = 955), a septorhinoplasty in 35% (n = 703) and a septoplasty in combination with a functional endoscopic sinus surgery in 17% (n = 342). In total, 86% (n = 1721) showed no complications at all during the follow-up period. In 0.25% (n = 5) a sensitivity disorder of the anterior palate occurred. Of the five cases with a postoperative numbness of the anterior palate four occurred after a septoplasty and the fifth occurred following a septorhinoplasty. CONCLUSION: At this current time, this is the largest study investigating postoperative numbness of the anterior palate retracing septoplasty or septorhinoplasty. As a result, the currently used techniques for the operations do not pose a risk for the incisive nerve despite close surgical manipulation to the nerves' course. Nevertheless, patients should be informed and educated about the possibility of an occurring sensitivity disorder regarding the anterior palate during informed consent.

Optic nerve injury in preoperative imaging is associated with visual improvement outcome in endoscopic optic nerve decompression.

OBJECTIVE: To evaluate potential clinical parameters having an impact on visual outcome after endoscopic optic nerve decompression in acute optic neuropathy patients. METHODS: A retrospective chart review of patients with acute optic neuropathy, who underwent endoscopic optic nerve decompression between June 2001 and November 2018 at an academic center was performed. Patients were divided into groups according to visual improvement after surgical treatment (yes/no). Following clinical parameters were compared between groups: perioperative steroid use, evidence of optic nerve affection in preoperative neuroimaging, additional optic nerve sheath incision, surgery delay and preoperative C-reactive protein (CRP) levels. Further subgroups analyses were conducted based on etiology (trauma/tumor). RESULTS: Among 32 included cases, 16 patients (50%) reported visual improvement after endoscopic optic nerve decompression. There was no significant difference in visual improvement between etiology subgroups (trauma: n = 9/20 (45%) vs. tumor: n = 7/12 (58.3%), p = 0.465). Tumor subgroup patients with visual improvement had a significantly higher prevalence of optic nerve affection in preoperative neuroimaging than those without visual improvement (p = 0.018, φ = 0.683). Perioperative steroid administration was negatively associated with visual outcome (p = 0.034, φ = 0.375). Nerve sheath incision, surgery delay and preoperative CRP levels did not have a significant impact on visual outcome (p > 0.05). CONCLUSION: Radiological findings can help as an indicator for surgical treatment since an affected optic nerve in preoperative neuroimaging resulted in better visual outcome after surgery. The use of steroids should be considered more carefully since it did not show any beneficial effect.

Sinonasal mucosal melanoma: treatment strategies and survival rates for a rare disease entity : A single center experience and review of literature.

BACKGROUND: Sinonasal mucosal melanoma (SNMM) is a rare disease entity comprising 0.4-1.3% of all melanomas. Surgery with free margins has been the primary treatment over decades. Neither the addition of radiotherapy nor chemotherapy could significantly improve outcome rates of this devastating malignancy. This study presents our clinical experience with SNMM over a 19-year period and summarizes the current body of literature on SNMM. METHODS: This retrospective analysis included 12 patients with SNMM treated from 2001 to 2019 at an academic center. Additionally, a literature review of the last 29 years on treatment and survival data of SNMM was conducted. RESULTS: Main initial symptoms were epistaxis and nasal obstruction. Of the patients 9 underwent endoscopic surgery, 6 received adjuvant therapy. 3 patients who did not undergo surgery, received chemoradiotherapy, radiotherapy alone, and chemotherapy alone, respectively. At the time of diagnosis 2 patients had distant metastases and 4 patients developed distant metastases during the course of the disease. Mean overall survival (OS) was 30.6 months, 3­year and 5­year OS were 25%, and 18.2%, respectively. CONCLUSION: Unspecific symptoms and hidden anatomic locations lead to delayed diagnosis and increased rates of metastatic dissemination. Distant metastasis is the main treatment failure in SNMM. Surgery with free margins remains the primary treatment for SNMM. Adjuvant radiotherapy might improve local control in individual cases but efficient systemic therapy is needed to improve outcome rates. To evaluate and define more effective targeted treatment options and improve outcome rates, homogeneous data and prospective multicentric analysis are needed.

Sex-specific differences in patients with nonmelanoma skin cancer of the pinna.

BACKGROUND: Generally, it is known that men are affected more frequently by nonmelanoma skin cancer (NMSC) than women. The aim of our study was to investigate the effect of sex on the characteristics of NMSCs of the pinna at the population that our center serves and to compare it with the international data. METHODS: We analyzed retrospectively the data of 225 patients with NMSC of the pinna. Sex-specific differences were investigated for basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) subgroups. RESULTS: The ratio of BCC to cSCC was determined in male patients at 1:1.3, in contrast in females it was identified at 4:1 (P = .001). CONCLUSION: In our study, a new aspect of the sex-dependent distribution of cSCC and BCC of the pinna was demonstrated. Women are affected four times more frequently by BCC than by cSCC, whereas in men this ratio is approximately equal.

DRH1 - a novel blood-based HPV tumour marker.

BACKGROUND: To date, no studies have successfully shown that a highly specific, blood-based tumour marker to detect clinically relevant HPV-induced disease could be used for screening, monitoring therapy response or early detection of recurrence. This study aims to assess the clinical performance of a newly developed HPV16-L1 DRH1 epitope-specific serological assay. METHODS: In a multi-centre study sera of 1486 patients (301 Head and Neck Squamous Cell Carcinoma (HNSCC) patients, 12 HIV+ anal cancer patients, 80 HIV-positive patients, 29 Gardasil-9-vaccinees, 1064 healthy controls) were tested for human HPV16-L1 DRH1 antibodies. Analytical specificity was determined using WHO reference-sera for HPV16/18 and 29 pre- and post-immune sera of Gardasil-9-vaccinees. Tumour-tissue was immunochemically stained for HPV-L1-capsidprotein-expression. FINDINGS: The DRH1-competitive-serological-assay showed a sensitivity of 95% (95% CI, 77.2-99.9%) for HPV16-driven HNSCC, and 90% (95% CI, 55.5-99.7%) for HPV16-induced anal cancer in HIV-positives. Overall diagnostic specificity was 99.46% for men and 99.29% for women ≥ 30 years. After vaccination, antibody level increased from average 364 ng/ml to 37,500 ng/ml. During post-therapy-monitoring, HNSCC patients showing an antibody decrease in the range of 30-100% lived disease free over a period of up to 26 months. The increase of antibodies from 2750 to 12,000 ng/ml mirrored recurrent disease. We can also show that the L1-capsidprotein is expressed in HPV16-DNA positive tumour-tissue. INTERPRETATION: HPV16-L1 DRH1 epitope-specific antibodies are linked to HPV16-induced malignant disease. As post-treatment biomarker, the assay allows independent post-therapy monitoring as well as early diagnosis of tumour recurrence. An AUC of 0.96 indicates high sensitivity and specificity for early detection of HPV16-induced disease. FUNDING: The manufacturer provided assays free of charge.