[Continuous intraoperative neuromonitoring (cIONM) in head and neck surgery-a review. German version]. / Kontinuierliches intraoperatives Neuromonitoring (cIONM) in der Kopf-Hals-Chirurgie ­ eine Übersicht.

Although the history of intraoperative neuromonitoring (IONM) dates back to the 19th century, the method did not evolve further than the mere differentiation of nerves until recently. Only the development of continuous IONM (cIONM) has allowed for non-stop analysis of excitation amplitude and latency during surgical procedures, which is nowadays integrated into the software of almost all commercially available neuromonitoring devices. The objective of cIONM is real-time monitoring of nerve status in order to recognize and prevent impending nerve injury and predict postoperative nerve function. Despite some drawbacks such as false-positive/negative alarms, technical artefacts, and rare adverse effects, cIONM remains a good instrument which is still under development. Active (acIONM) and passive (pcIONM) methods of cIONM are described in literature. The main fields of cIONM implementation are currently thyroid surgery (in which the vagal nerve is continuously stimulated) and surgery to the cerebellopontine angle (in which the facial nerve is either continuously stimulated or the discharge signal of the nerve is analyzed via pcIONM). In the latter surgery, continuous monitoring of the cochlear nerve is also established.

Continuous intraoperative neuromonitoring (cIONM) in head and neck surgery-a review.

Although the history of intraoperative neuromonitoring (IONM) dates back to the 19th century, the method did not evolve further than the mere differentiation of nerves until recently. Only the development of continuous IONM (cIONM) has allowed for non-stop analysis of excitation amplitude and latency during surgical procedures, which is nowadays integrated into the software of almost all commercially available neuromonitoring devices. The objective of cIONM is real-time monitoring of nerve status in order to recognize and prevent impending nerve injury and predict postoperative nerve function. Despite some drawbacks such as false-positive/negative alarms, technical artefacts, and rare adverse effects, cIONM remains a good instrument which is still under development. Active (acIONM) and passive (pcIONM) methods of cIONM are described in literature. The main fields of cIONM implementation are currently thyroid surgery (in which the vagal nerve is continuously stimulated) and surgery to the cerebellopontine angle (in which the facial nerve is either continuously stimulated or the discharge signal of the nerve is analyzed via pcIONM). In the latter surgery, continuous monitoring of the cochlear nerve is also established.

Platelet-rich fibrin and bovine porous bone mineral vs. platelet-rich fibrin in the treatment of intrabony periodontal defects.

BACKGROUND AND OBJECTIVE: Bovine porous bone mineral (BPBM) is a xenograft that has been successfully utilized in periodontal regeneration. Platelet-rich fibrin (PRF) is a leukocyte and platelet preparation that concentrates various polypeptide growth factors and therefore has the potential to be used as regenerative treatment for periodontal defects. The purpose of this study was to examine the suitability of autologous PRF as regenerative treatment for periodontal intrabony defects in humans and to examine the ability of BPBM to augment the regenerative effects exerted by PRF. MATERIAL AND METHODS: Using a split-mouth design, 17 paired intrabony defects were randomly treated either with PRF or with PRF-BPBM combination. Re-entry surgeries were performed at 6 mo. Primary study outcomes were changes in pocket depth, attachment level and defect fill. RESULTS: Preoperative pocket depths, attachment levels and transoperative bone measurements were similar for the PRF and PRF-BPBM groups. Postsurgical measurements revealed a significantly greater reduction in pocket depth in the PRF-BPBM group (4.47±0.78 mm on buccal and 4.29±0.82 mm on lingual sites) when compared with the PRF group (3.35±0.68 mm on buccal and 3.24±0.73 mm on lingual sites). The PRF-BPBM group presented with significantly greater attachment gain (3.82±0.78 mm on buccal and 3.71±0.75 mm on lingual sites) than the PRF group (2.24±0.73 mm on buccal and 2.12±0.68 mm on lingual sites). Defect fill was also greater in the PRF-BPBM group (4.06±0.87 mm on buccal and 3.94±0.73 mm on lingual sites) than in the PRF group (2.21±0.68 mm on buccal and 2.06±0.64 mm on lingual sites). CONCLUSION: The results of this study indicate that PRF can improve clinical parameters associated with human intrabony periodontal defects, and BPBM has the ability to augment the effects of PRF in reducing pocket depth, improving clinical attachment levels and promoting defect fill.

Severe dyspnea as atypical presenting symptom of Madelung's disease.

Madelung's disease (benign symmetrical lipomatosis) is a rare disease of unknown etiology manifesting as symmetric abnormal deposits of adipose tissue in the head, neck and upper trunk. We report a case of a 58-year-old man with a long lasting Madelungs disease in whom progressive fatty tissue accumulation caused a severe inspiratory dyspnea as atypical presenting symptom. The etiopathogenetic, clinico-diagnostic and therapeutic aspects of this rare disease are discussed. Due to its progressive but not so easily predictable enlarging behavior Madelung's disease has not only aesthetic but also functional and sometimes life threatening consequences which need to be treated.

[The effect of smoking and forced use of the voice to development of the vocal polyps].

Dysphonia is often caused by polyps which are benign changes of pseudotumors. With their presence they are hampering with glotis oclusion. Laryngomicroscopy of general and endotracheal anaesthesia has been preformed on all of the patients. Microsurgical technique has been used to remove the polyps. Bioptic material was analyzed in pathophysiological laboratory of clinic of pathology in Banjaluka. All of the results were presented through tables and graphic representations. Frequency of polyps through age and sex groups, along with the examination of ethyological factors in emergence of polyps of vocal cords. Results are in accordance with the results of other authors who were involved in similar problematics. Through analysis of our data we percieve that the abuse of voice is part of ethiological factors that lead not only to emergence of vocal fold lesions but aswell as other benign changes.

[What do we need to help laryngectomized speeking?].

Multidisciplinary approach in rehabilitation of laryngectomized patients is the basic of esophageal voice and speech establishing. Well trained and dedicated stuff is cornerstone for such helpless patients. Communication Disorders Care Center and Laryngectomized Patients Society are minimal administrative precautions in organized community. Modern technology implementation gives us objective evaluation of therapy effects, that is 84% of successful treatment in our daily work.

Nonvibrating segment predicting glottis carcinoma.

Endovideolaryngostroboscopy is the obliged evaluation tool in our everyday practice. Standardized protocol in management of broad spectrum of vocal pathology is useful in clinical, scientific and educational evaluation of patient from the first interview till the end of the treatment. Using of contemporary computerised multidimensional analysis of stroboscopic image we are approaching to optimum evaluation of any kind of interpersonal communication disorder. There were 66 patients in prospective clinical study of correlation between suspect endovideolaryngostroboscopic findings and histo-pathology verification of glottis carcinoma. Asymmetric and irregular vibrations with absent mucosal wave or absent vibrations of one part or of the whole vocal fold was improved as carcinoma in 85% of patients. The most frequent diagnosis was Ca planocellularae invasivum G2 NG 2, with subsequent open chordectomy. In every case of hoarseness longer more than 14 days, endovideolaryngostroboscopy is the golden standard for evaluating the need for microlaryngoscopy and biopsy.

[Phoniatricians aspect of international statistical classification of diseases and related health problems].

INTRODUCTION: In everyday phoniatrician practice there are problems in finding adequate coding in current version of International Classification of Diseases. There is grey area for additional explanation under the official diagnosis and its code in Computer program window, but that has bad consequences on efficacy in writing the final medical report. OBJECTIVE: Suggestions for solving this problem that can contribute in next Revision are presented. METHOD: The comparation between diagnoses in 7 years period of Phoniatric Department everyday practice and given diagnoses in current version of International Classification of Diseases. RESULTS: Certain percent of diagnoses that are overviewed during last 7 years in our Phoniatric Department has no adequate expression in given diagnoses in Tenth Revision. One can say that there is some kind of communication disorder. CONCLUSION: This is the moment for Communication Disorders Care Center experts to participate in constitution of widespread acceptable nomenclature. The role of phoniatrician is necessary and logical in this system. The phoniatrician aspect of contribution in next Revision, is presented.

[Laser surgery of supraglottic laryngeal carcinoma].

The limited excision addresses small superficial lesions affecting free edge of the epiglottis, the aryepiglottic fold or the superior edge of the arytenoid. The median supraglottic laryngectomy excluding the pre-epiglottic space addresses small superficial T1 lesions of the endolaryngeal epiglottis. The incision line extends to the pre-epiglottic space but does not aim at removing the pre-epiglottic space entirely. The pharyngo-epiglottic folds, aryepiglottic folds, and ventricular folds are preserved. The median supraglottic laryngectomy including the pre-epiglottic space addresses T1 and T2 lesions of the endolaryngeal epiglottis. The entire pre-epiglottic space is removed as far as possible. Depending on extent of the lesion, the resection can include one or two ventricular bands and the aryepiglottic folds. The lateral supraglottic laryngectomy addresses lesions affecting the three folds or T1 and T2 lesions of the aryepiglottic fold. The procedure removes free edge of the epiglottis ipsilateral to the lesion, the area of the three folds and the aryepiglottic fold. The resection can include the inner wall and anterior angle of the pyriform sinus, the entire ventricular fold and the arytenoid (provided it is mobile).

[Orbital complications of rhinosinusitis].

INTRODUCTION: Orbital complications were observed in 53 patients (1.35%, n=53/3912 of all treated patients; 11.04%, n= 53/480 of hospitalized patients). Complications in the orbit can occur in 3-5% of adults with the inflammatory condition of sinuses, while the percentage in children ranges from 0.5-8%. OBJECTIVE: The objective of our work was to determine the frequency of the occurence of orbital complications of the rhinosinal inflammatory origin in a group of adults and children. METHOD: The retrospective analysis of patients treated of rhinosinusitis in the period 1992 to 2007, in the Clinical Center in Kragujevac. RESULTS: In the period of 15 years, a total number of 3912 patients were treated for inflamatory conditions of paranasal cavities. Orbital complications were found in 53 patients (1.35%, n=53/3912 of all treated patients). The number of children showing orbital complications caused by rhinosinusitis was 0.79%, while the number of adults was 1,88%. Acute rhinosinusitis in children was manifested as orbital complication in 14 patients (n=14/15, 93.33%), while 33 adults (n=33/38, 86.84%) had the exarcerbation of the chronic rhinosinusitis at the time of diagnosis of orbital complication. 80% of examined children had the maxillary and ethmoid sinus infected (n=12/15), while the adults most often had polysinusitis (n=22/38, 57.89%). In the juvenile age the most frequent complication was the cellulitis of the orbite (n=7/15, 46.66%), while in the adults it was the subperiostal absces (n=14/38, 36.84%). The adults were mostly treated surgically (n=31/38, 81.58%), while the children were treated by using conservative treatment (n=13/15, 86.67%). There were no cases of mortality. CONCLUSION: The prevention of complications is based on the adequate and timely treatment of acute sinusitis in children, as well as the curative treatment of chronical processes in adults.

[A-mode ultrasonography and roentgenography in diagnosing chronic nonpolypoid maxillary rhinosinusitis].

OBJECTIVES: The aim is to demonstrate diagnostic alternatives for A-mode ultrasonography in examining chronic nonpolypoid rhinosinusitis, its implementation, as well as its advantages and disadvantages in regards to roentgenography. METHOD: The prospective research conducted included patients with chronic nonpolypoid rhinosinusitis, at 79 maxillary sinuses. Chronic diseases are classified into two separate categories depending on the clinical entity. Comparative analysis of the ultrasound and roentgenography findings was conducted for both, while the status of the maxillary sinuses obtained by sunusoscopy provided the gold standard. RESULTS: Generally speaking, the reliability of the A-mode ultrasonography in diagnosing chronic nonpolypoid diseases in maxillary sinuses was of a somewhat greater degree in comparison to roentgenography, amounting to 72.15% in relation to 60.76%. There is no statistically significant divergence in relation to the foregoing methods. A-mode ultrasonography is more helpful in the process of identifying liquid contents, and can be less utilized in identifying hypertrophic mucous membrane. CONCLUSION: Ultrasonography is efficient, economical and quite simple for the implementation. Its chief advantage is to be perceived in the fact that both the patient and the examiner avoid being exposed to ionized radiation. Ultrasonography and roentgenography suggest lesser degree of utility and represent a triage method in detecting chronic nonpolypoid pathological conditions.

[Postoperative morbidity and quality of live in patients after radical and modified radical neck dissection].

Useful of radical neck dissection would not be questioned if the effects would be perfect. When postoperative morbidity is associated with oncological shortage of radical neck dissection in functional and cosmetics disfunction, looking for a new therapeutics procedures are justify. In our study were 319 patients. They were treated in period from 01 January 2000 to 31 December 2002. The follow-up was 5 year. We tried to consolidate distribition of n. accesorius operative injuries in modified radical neck dissection and relationship beetwen shoulder pain and shoulder droop after modified and radical neck dissection. Injured n.accesorius in modified radical neck dissection was significantly decreased in patients with modified radical neck dissection. The frequence of patients is significantly different (chi m2=26.662; df = 1; p<0.01) in categories of complications of n.accesorius (shoulder pain, shoulder droop). Shoulder pain and shoulder droop were significantly decreased in modified radical neck dissection (p<0.01).

Vocal fold masses removal--the sub epithelial micro flap technique.

Vocal fold mass removal techniques were significantly modified back in 1970s by Hirano's laminar vocal structure and physiology of phonation works, as well as Titze's vibratory vocal cycle works. New methods were to come. Removing the lession by maximum preservation of vocal laminar microstructure (lamina propria and epithelium) and minimal damage of surrounding normal vocal tissue, was pointed out. Microflap technique is based on presenting the superficial layer of lamina propria with the lesion and removing the lession without damage of the mucosa. Preserving of the mucosal layer provides the shield for vibratory substructures. There are two elementary approaches for microflap: lateral and medial. Lateral microflap technique enables better identification of vocal ligament and lowers the risk of it's injury, particulary when scars and tightly adherent lessions are present. This technique has been used in case of big or diffuse lesions, such as vocal oedema or vocal lygament identification difficulties (e.g. vocal scarification). Medial microflap technique seems to be appropriate in removing smaller, localised lessions, such as cysts and vocal polyps. Our 45 patients experience is presented in this article, in 30 patients lessions were removed by lateral microflap technique (46 vocal cords in total), while 15 patients were treated by medial microflap technique. The outcome was assumed by endovideolaryngostroboscopic analysis of glottal occlussion and mucosal wave prior and following to the procedure. Reinke oedema management results were analysed separately.

Conservative treatment vs phonosurgery.

In Phoniatric Dpt. everyday practice we try to keep specific multidisciplinary approach to the communication disorders, that includes an expert team using modern technology. Over the last six years we have treated 110 singers (3% of all new cases) and the results of their diagnostic and therapeutic management are presented here. There were 67 women and 43 men, 41 were smokers and 69 nonsmokers. The singing genres included 24 pop, 41 folk, 8 ethnic, 29 choral and 8 opera singers. The therapy success was compared with the demographic parameters, level of education and music genres across the subjects. A precise history, clinical examination, endovideolaryngostroboscopy and multidimensional computer analysis of voice and speech was carried out by two phoniatricians, two logopeds, two nurses and one clinical psychologist. Additional consultations were carried out by audiologists, allergists, endocrinologists, chest physicians, gastroenterologists and neurologists where necessary. We suggest that the gold standard is conservative therapy, with phonosurgery if conservative measures fail. We also suggest that an annual systematic examination is optimal in preventing disease in professional singers.

[Dilemmas and controversies related to cancers of the anterior laryngeal commissure]. / Dileme i kontroverze karcinoma prednje komisure larinksa.

From diagnostic and therapeutical aspect, the cancers of the anterior laryngeal commissure are the separate category in glottic cancers. But, they have not been individually classified in the majority of statistical reports, and, therefore, the incidence of the anterior commissural cancer should be taken with precaution. The issue of therapeutical strategy is controversial, considering the options and limitations of resections of the anterior commissural tumors, within the conception of oncological radicalism. Dilemmas are being especially faced with in radiotherapy, given the failures and unsatisfactory radiotherapeutical results. The prospective clinical study included the analysis of the incidence of primary and secondary cancers of the anterior commissure of the larynx. The follow-up of five-year survivals allowed for the establishment of efficiency of the applied therapeutical methods. The results of five-year survival in patients treated by primary surgery were highly more significant in relation to results obtained by radiotherapy of patients.

[Onco-surgical significance of anatomo-morphological specificity of glottic region of the larynx]. / Onkohirurski znacaj anatomo-morfoloskih specificnosti glotisne regije larinksa.

Glottis is a medium level of the larynx, involving the vocal cords, vocal process of arytenoid cartilage, and the anterior and posterior commissures. This region of heterogeneous histomorphological structure has specific characteristics: the internal striated muscles, the outer and inner perichondrium, atypical intra-cartilaginous areas of ossification, and unusual muscular insertion to cartilage. Microtomy of 3 thick successive sections was performed at the level of the upper surface of vocal cords. Standard histological staining methods were used. Microphotographs were taken by light microscope under different magnification along with histomorphometric measurements. Cancer spread is partially restricted by anatomic barriers: vocal ligament and tendon of the anterior commissure, and subsequently by the elastic cone. Easier tumor extension may be due to absence of the internal perichondrium and ossification of thyroid cartilage. Microvascularization of the anterior commissure is significant for tumor spread in glottis and paraglottic space. The role of commissural lymph network in local spread of the cancer is completely vague. It is certain that there are causes, still unrecognized, which have an effect on the pathways and direction of malignant tumor spread.

[Extended supra glottic laryngectomies]. / Prosirene supraglotisne laringektomije.

In the period 1976-1998, 408 patients with supraglottic laryngeal cancer were primarily treated by surgery using the method of supraglottic laryngectomy. Classical supraglottic laryngectomy was performed in 355 patients, while 53 underwent extended supraglottic laryngectomy. The objective of the study was to analyze the success of the extended supraglottic laryngectomy in relation to classical supraglottic laryngectomy in indicated cases. T1 tumor was found in 171 (42%) patients, T2 in 212 (52%), while T3 was found in 25 (6%) cases. Local recurrence developed in 3 out of 53 patients operated by the extended supraglottic laryngectomy technique, and in 17 out of 355 operated by classical supraglottic laryngectomy (chi2=0.075, DF=1, p=0.784; Yates=0.00, p=1.00). Five-year survival of patients operated by the extended supraglottic laryngectomy was reported in 40 out of 53 patients, while survival of patients operated by classical supraglottic laryngectomy was noted in 270 out of 355 cases (chi2=0.004, DF=1, p=0.926; Yates=0.00, p=1.00). There was no significant difference of local recurrence and five-year survival between patients treated by classical and extended supraglottic laryngectomy.

[Surgery treatment of laryngeal carcinoma T1]. / Hirursko lecenje T1 karcinoma glasnica.

The early stage cancer of the glottis, including Tis, T1a and T1b stages, are the most common forms with the incidence rates ranging from 25% to 85%. The therapy of early glottic cancer is usually successful for two reasons. First, true glottic cancer produces early symptoms and it is relatively easy to remove. Second, glottis is rather poor with lymph pathways so the regional metastases are rare, less than 1%. Due to role of the larynx in phonation, respiration and swallowing, the cancer of this region and its treatment has a great impact to the quality of life. Retrospective study involved ten-year period, from January 1990 to January 2004. At the Institute for Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, 858 surgical and 54 endoscopic CO2 laser-assisted resections were performed for glottic cancers of larynx of Tis-T2 stages. Glottic tumors were treated by Types III, IV and Va chordectomies according to classificaiton of endoscopic chordectomy defined by the European Laryngological Society. Analyzing the operated patients, as well as the type of the applied surgery, that is, endoscopic-laser and classic surgery, the authors attempted to clarify the dilemmas relating to the indications for one or another type of surgical intervention. The patients who had undergone primary radiotherapy were excluded from the analysis.

[Radical surgery of the malignant laryngeal tumors]. / Radikalna hirurgija malignih tumora larinksa.

Modern therapeutical protocols for treatment of T3 and T4 malignomas of the larynx are not adjusted, because there are attempts to treat these diseases with non-operative methods (such as chemo- and radiotherapy) in order to preserve the organ. The aim of the study was to establish today's results of the surgical treatement of patients with T3 and T4 laryngeal malignoma. We studied the group of patients with laryngeal carcinoma, who had undergone total laryngectomy, during the period of eight years (1990-1997). The patients' data was submitted from medical documentation, it was filled in specially designed questionnaries and was statistically reviewed. During this eight-year-period, 1054 total laryngectomies were done. The five-years survival rate, established in the group of patients who had undergone total laryngectomiy is 308/794 (39%). In the patient group where total laryngectomy was salvage surgery after radiotherapy, the five-years survival rate is 47/172 (27%). In the patient group where total laryngectomy was salvage surgery after conservative or reconstructive surgery, the five-years survival rate is 28/84 (33%). Despite diagnostical and therapeutical achievements, prognosis for T3 and T4 malygnoma of the larynx was not significantly approved in the last few decades.