EAONO/JOS classification for acquired cholesteatoma: evaluating the impact of the number of affected sites on treatment and outcomes.

PURPOSE: The European and Japanese system for cholesteatoma classification proposed an anatomical differentiation in five sites. In stage I disease, one site would be affected and in stage II, two to five. We tested the significance of this differentiation by analyzing the influence of the number of affected sites on residual disease, hearing ability and surgical complexity. METHODS: Cases of acquired cholesteatoma treated at a single tertiary referral center between 2010-01-01 and 2019-07-31 were retrospectively analyzed. Residual disease was determined according to the system. The air-bone gap mean of 0.5, 1, 2, 3 kHz (ABG) and its change with surgery served as hearing outcome. The surgical complexity was estimated regarding the Wullstein's tympanoplasty classification and the procedure approach (transcanal, canal up/down). RESULTS: 513 ears (431 patients) were followed-up during 21.6 ± 21.5 months. 107 (20.9%) ears had one site affected, 130 (25.3%) two, 157 (30.6%) three, 72 (14.0%) four and 47 (9.2%) five. An increasing number of affected sites resulted in higher residual rates (9.4-21.3%, p = 0.008) and surgical complexity, as well poorer ABG (preoperative 14.1 to 25.3 dB, postoperative 11.3-16.8 dB, p < 0.001). These differences existed between the means of cases of stage I and II, but also when only considering ears with stage II classification. CONCLUSION: The data showed statistically significant differences when comparing the averages of ears with two to five affected sites, questioning the pertinence of the differentiation between stages I and II.

Cellular density and variability in laryngeal and pharyngeal squamous cell carcinoma using confocal laser endomicroscopy.

OBJECTIVE: Confocal laser endomicroscopy (CLE) allows the visualization of epithelium in a thousand-fold magnification. This study analyzes the architectural differences at the cellular level of the mucosa and squamous cell carcinoma (SCC). PATIENTS AND METHODS: A total of 60 CLE sequences recorded in 5 patients with SCC undergoing laryngectomy between October 2020 and February 2021 were analyzed. The corresponding histologic sample derived from H&E staining was assigned to each sequence, capturing CLE images of the tumor and healthy mucosa. In addition, the cellular structure analysis was performed to diagnose SCC by measuring the total number of cells and cell size in 60 sequences in a fixed field of view (FOV) with 240 µm in diameter (45,239 µm2). RESULTS: Out of 3,600 images, 1,620 (45%) showed benign mucosa and 1,980 (55%) SCC. The automated analysis yielded a difference in cell size, with healthy epithelial cells being 171.9±82.0 µm2 smaller than SCC cells, which were 246.3±171.9 µm2 and showed greater variability in size (p=0.037). In addition, due to the probe's fixed FOV, there was a difference in cell count with a total of 188.7±38.3 and 124.8±38.6 cells in images of normal epithelium and SCC (p<0.001), respectively. Regarding cell density as a criterion for the differentiation of benign/malign, using a cut-off value of 145.5 cells/FOV, we obtained sensitivity and specificity of 88.0% and 71.9%, respectively. CONCLUSIONS: SCC reveals marked differences at a cellular level compared to the healthy epithelium. Our results further support the importance of this feature for identifying SCC during CLE imaging.

The influence of obstructive sleep apnea and continuous positive airway pressure on the nasal microbiome.

OBJECTIVE: The aim of this study was to investigate the influence of obstructive sleep apnea and continuous positive airway pressure on the nasal microbiome. PATIENTS AND METHODS: Endonasal swabs from the olfactory groove of 22 patients with moderate and severe obstructive sleep apnea (OSA) and a control group of 17 healthy controls were obtained at the Department of Otorhinolaryngology of the Friedrich-Alexander-Universität Erlangen-Nürnberg. 16S rRNA gene sequencing was performed to further evaluate the endonasal microbiome. In a second step, the longitudinal influence of continuous positive airway pressure (CPAP) therapy on the nasal microbiome was investigated (3-6 and 6-9 months). RESULTS: Analysis of the bacterial load and ß-diversity showed no significant differences between the groups, although patients with severe OSA showed increased α-diversity compared to the control group, while those with moderate OSA showed decreased α-diversity. The evaluation of longitudinal changes in the nasal microbiota during CPAP treatment showed no significant difference in α- or ß-diversity. However, the number of bacteria for which a significant difference between moderate and severe OSA was found in the linear discriminant analysis decreased during CPAP treatment. CONCLUSIONS: Long-term CPAP treatment showed an alignment of the composition of the nasal microbiome in patients with moderate and severe OSA as well as an alignment of biodiversity with that of the healthy control group. This change in the composition of the microbiome could be both part of the therapeutic effect in CPAP therapy and a promoting factor of the adverse side effects of the therapy. Further studies are needed to investigate whether the endonasal microbiome is related to CPAP compliance and whether CPAP compliance can be positively influenced in the future by therapeutic modification of the microbiome.

TIMP-1 as a biomarker in obstructive sleep apnea: screening, monitoring, risk stratification, and a step towards precision medicine.

OBJECTIVE: The diagnosis of obstructive sleep apnea (OSA) is a complex time- and resource-intensive diagnostic procedure. Since tissue inhibitors of matrix metalloproteinases (TIMP's) are involved in various pathophysiological processes and are correlated with a high cardiovascular risk, TIMP's appear to be a suitable candidate for an OSA-biomarker. PATIENTS AND METHODS: In a prospective controlled diagnostic study, TIMP-1 serum levels of 273 OSA-patients and controls were analyzed for correlation with OSA severity, BMI, age, sex, cardio-/ cerebrovascular comorbidities. Furthermore, longitudinal medium- and long-term effects of CPAP-treatment (n=15) on TIMP-1-levels were investigated. RESULTS: TIMP-1 was clearly linked to OSA as well as to disease severity (mild, moderate, severe; each p<0.001) and was not influenced by age, gender, BMI, or cardio-/cerebrovascular comorbidities. ROC curve analysis revealed an AUC of 0.91 ± 0.017 SE (p<0.001), suggesting a TIMP-1 cut-off value of 75 ng/ml (sensitivity 0.78; specificity 0.91) being especially sensitive for patients with severe OSA (sensitivity 0.89; specificity 0.91). The likelihood ratio was 8.88, while the diagnostic odds ratio was 37.14. CPAP-treatment led to a significant decrease of TIMP-1 after 6-8 months (p=0.008). CONCLUSIONS: TIMP-1 seems to fulfill the preconditions for a circulating OSA-biomarker: disease-specific with a mandatory presence in affected patients, reversible on treatment, reflects disease severity and provides a cutoff value between the healthy state and disease. In the clinical routine, TIMP 1 may help to stratify the individual OSA-associated cardiovascular risk and to monitor the treatment response to CPAP-therapy as a further step towards providing a personalized therapy.

Phantom-based prospective analysis of the accuracy of photo registration technology in electromagnetic navigation of the frontal skull base.

OBJECTIVE: This prospective study compared the accuracy of two different company-specific registration methods (Fiagon GmbH, Hennigsdorf, Germany) in the electromagnetic navigation of the frontal skull base. A newly developed photo registration technology (Fiagon tracey©) promises an increase in accuracy and user-friendliness, but there is no phantom-based prospective study comparing the new method with the classic approach of tactile surface registration. MATERIALS AND METHODS: A phantom skull was prepared with 27 markers in the sagittal, axial and coronary planes, and their reference coordinates were determined using a navigational CT (low dose, slice 0.6 mm). Subsequently, 20 runs of automatic photo registration and tactile surface registration were carried out, and the resulting marker coordinates were compared with the reference coordinates. The target registration error (TRE) of the 27 markers was assessed and compared between the two methods using a 2-factor ANOVA with repeated measures. RESULTS: The mean TRE using surface registration was 1.97 mm ± 0.57, while the mean TRE of the automatic photo registration was 1.54 mm ± 0.24 (p < 0.001). In a subgroup analysis limited to markers in anatomical regions of clinical relevance in terms of paranasal sinus surgery, the mean TRE for the photo registration procedure can even be reduced to 1.29 mm (± 0.43) compared to tactile registration (1.80 mm; ±0.50; p=0.01). CONCLUSIONS: Photo registration is a promising new technology in the field of electromagnetic navigation in paranasal sinus surgery. This prospective phantom-based study showed that the photo registration method achieves a significantly lower target registration error (1.29 mm) compared to the surface-based tactile registration procedure (1.80 mm).

Analysis of surgical treatment strategy and outcome factors in persistent tracheoesophageal fistula: a critical analysis of own cases and review of the literature.

OBJECTIVE: Surgical closure of persistent tracheoesophageal fistulas (TEFs) is complex. Most patients present with multiple risk factors, which may negatively impact the outcome and influence the treatment strategies. PATIENTS AND METHODS: This retrospective study included 22 patients presenting with persistent TEFs. Preoperative RT, comorbidities, tissue conditions of the TEFs and neck skin, and surgical techniques were evaluated regarding a possible impact on success rates and outcome. RESULTS: 21 patients were operated, 95.45% with final success. However, in 52.39% repeated surgery was needed. Final closure of TEFs was achieved in 91.47% only after more invasive surgery was performed. The surgical technique applied had the most significant impact on success rates and outcome compared to all other risk factors analyzed. Our own data and that of the literature point out that the surgical strategy should be adapted to the patients' individual risk factors. CONCLUSIONS: According to the literature, surgical closure of persistent TEFss is demanding. Our data suggest that, considering that the majority of patients with persistent TEFs exhibit multiple risk factors, early performance of more invasive surgery seems associated with a better outcome.

Endoscopic laser diverticulotomy in Zenker's diverticulum: experiences with basal wound sealing using a collagen-fibrin patch.

OBJECTIVE: Very few reports investigated techniques of closure of the basal wound area to reduce severe complications like mediastinitis after endoscopic laser diverticulotomy. In this study, we report our experiences after routine use of a collagen-fibrin sealant patch for basal wound covering after laser diverticulotomy in consideration of postoperative complications and recurrence rates. PATIENTS AND METHODS: This retrospective study was conducted in a tertiary referral center and university hospital. Endoscopic laser diverticulotomies performed in our hospital between January 2006 and July 2018 were included. After complete transection of the laser septum of the diverticulum, we placed a collagen-fibrin patch onto the basal wound area to cover the opening to the mediastinum. Patient records were evaluated to assess the occurrence of perioperative complications, and the data were compared with those reported in the literature. RESULTS: A total of 127 endoscopic laser diverticulotomies were performed in 109 patients (71 men, 38 women) suffering from Zenker's diverticulum. Morality rate was 0%, in particular no mediastinitis was observed. Mediastinal emphysema was observed in two patients (1.6%), and temporary or persistent recurrent nerve palsy in one patient (0.8%) each. The mean follow-up period was 71.6±5.16 months. Recurrent symptomatic diverticulum was observed in 19.3% of the patients. CONCLUSIONS: These findings suggest that use of a collagen-fibrin sealant patch in endoscopic laser diverticulotomy may contribute to the safety of endoscopic controlled laser diverticulotomy without comprising the success rates.

Is extracapsular dissection for pleomorphic adenoma rather a euphemism for enucleation that jeopardises the intactness of the capsule?

The aim of this study was to compare several surgical modalities with respect to the incidence of positive margins and focal capsular exposure of pleomorphic adenoma of the parotid gland. The clinical records and histopathological findings of all patients who underwent parotidectomy for pleomorphic adenoma between 2006 and 2020 were retrospectively evaluated (n = 845). The lesion was removed by extracapsular dissection in 577 cases (68%) and facial nerve dissection in 268 (32%). Our analysis did not reveal a statistically significant difference between the examined modalities regarding positive margins (p=0.648) or capsular exposure (p=0.112). Recurrences were detected in 7/845 cases (0.82%) with a mean (range) follow-up time of 82.3 (6-183) months. The choice of surgical method does not seem to have a significant effect on the incidence of positive margins, or on the capsular exposure of a pleomorphic adenoma.

Primary parotid gland lymphoma: pitfalls in the use of ultrasound imaging by a great pretender.

The aim of this study was to highlight several misleading imaging and clinical aspects of parotid gland lymphoma, taking our personal experience and relevant literature reports into consideration. The records of all patients diagnosed with lymphoma in the parotid gland between 2005 and 2017 were examined retrospectively. Sixty-seven patients were included in this study. The mean age was 61.4 years. The most frequent histological entities were marginal zone B-cell lymphoma (31.3%) and follicular lymphoma (28.4%). The tumour was stage I in 35 cases (52.2%), stage II in 13 cases (19.4%), stage III in 11 cases (16.4%), and stage IV in eight cases (11.9%). B symptoms were seen in only three patients (4.5%). The diagnosis was made after parotidectomy in 51 cases (76.1%), by core needle biopsy in 14 cases (20.9%), and by means of open biopsy in the remaining two cases (3.0%). Parotid gland lymphoma represents a diagnostically challenging, multifaceted entity that can easily mimic both benign and malignant conditions. This entity should be included in the differential diagnosis of almost all types of parotid lesion, as it seems to play the role of a great pretender.

Simultaneous application of ultrasound and sialendoscopy: experience in the management of stenosis and other non-sialolithiasis-related salivary gland disorders.

OBJECTIVE: To assess the value of the simultaneous application of ultrasound and sialendoscopy (US+SE) in several salivary gland diseases not caused either by sialolithiasis or by tumours. PATIENTS AND METHODS: US+SE are routinely used in patients with inflammatory, obstructive, and other non-tumorous major salivary gland diseases. In patients in whom US and SE as single investigation tools were not conclusive or not useful in the management of several non-sialolithiasis-related conditions (stenoses, ductal anomalies, ductal trauma, space-occupying paraductal lesions), both methods were used simultaneously for diagnosis and treatment. RESULTS: US+SE were used simultaneously in 44 patients for 56 indications. Stenosis was managed in 36 cases (81.8%) and in thirty-eight of the indications (67.9%) with simultaneous US+SE. The successful opening was achieved in 23 (63.9%), conservative and/or ablative treatment was indicated in 13 (36.1%), and further imaging was indicated in two (5.5%) of these cases. Post-traumatic or postinfectious complications were managed in 12 (27.3%) of all cases, and isolated ductal anomalies and paraductal space-occupying lesions were assessed in three cases (8.3%) each. In all instances, simultaneous US+SE clearly improved the management in diagnosis and/or therapy. CONCLUSIONS: Simultaneous application of US+SE provided additional information that proved to be valuable for diagnosis, planning, and treatment in several non-sialolithiasis-related conditions such as stenoses, ductal anomalies, ductal trauma, and space-occupying paraductal lesions.

Pleomorphic adenoma compared with cystadenolymphoma of the parotid gland: which is more common?

The aim of this single-institution, observational study was to detect and explain any potential changes in the incidence of pleomorphic adenoma and cystadenolymphoma over a period of 19 years. The records of all patients who were treated for benign parotid tumours between 2000 and 2018 were evaluated and the data analysed to detect any potential changes in the incidence over time. A total of 2988 patients were studied, 1150 of whom had cystadenolymphomas (39%), and 1047 pleomorphic adenomas (35%). The dominance of cystadenolymphomas was first noted during the period 2004-2007 and remained stable throughout the following years (p=0.05). The predominant incidence of cystadenolymphomas has increased over time and is not expected to change in the next decades.

Intraductal lithotripsy in sialolithiasis with two different Ho:YAG lasers: presetting parameters, effectiveness, success rates.

OBJECTIVE: To compare two different Ho:YAG laser systems in relation to the preset parameters and their effectiveness for intraductal fragmentation of the salivary stones. PATIENTS AND METHODS: We made a retrospective study in two tertiary referral centers (Department of ENT, Head and Neck Surgery, University of Erlangen-Nuremberg, Germany and the MacKay Memorial Hospital, Taipei, Taiwan). Patients with a diagnosis of sialolithiasis were treated in Erlangen and Taipei. The Erlangen patients were treated using the Calculase II™ Ho:YAG laser (Karl Storz, Tuttlingen, Germany) at 4 Hz, 1.2 J (4.8 W) and the MacKay patients were treated using the VersaPulse® PowerSuite™ Ho:YAG laser (Lumenis Ltd., Yokneam, Israel) at 6 Hz, 0.5 J (3 W). RESULTS: A total of 12 patients with 12 stones were treated in Erlangen and 54 with 75 stones in Taipei. The submandibular stones were present in 50% and 86.7% of cases, respectively. The complete fragmentation was achieved in all of the treated stones in both groups; 100% and 92.6% of the patients were stone-free, 100% and 94.4% of the patients became symptom-free, respectively. 33% of the Erlangen patients had multimodal treatments. The glands were preserved in all cases in both centers. CONCLUSIONS: The Ho:YAG laser proved to be effective in the treatment of sialolithiasis. Stone size, location, and involved gland were important additional parameters. Our experience and the literature results show that the laser presetting with a frequency of 3-6 Hz, an energy level of 0.5-1.2 J, and effective power of between 3 and 4.8 W is sufficient to achieve maximum success without any increased risk for complications.

Watchful waiting in carefully selected metachronous cystadenolymphomas of the parotid gland: a reliable option?

The aim of this study was to evaluate the potential of watchful waiting in the treatment of metachronous cystadenolymphomas, taking the experience of our department into consideration. All patients suspected of having a metachronous cystadenolymphoma, and who had a minimum follow-up time of 12 months, were studied (n = 26). Data about the growth rate, number of lesions, and symptoms of inflammation were recorded. Mean (range) follow-up was 36 (13-94) months. Metachronous tumours developed in three cases on the ipsilateral side, in 22 cases on the contralateral side, and on both sides in one case. The mean rate of growth /lesion was 15% /year (range: 22%-158%). There were no signs of local inflammation. The extreme variability in the behaviour of metachronous cystadenolymphomas points to the need for an individualised approach, accurate investigation of the sonographic characteristics, and continuous watchful waiting in affected patients.

Extracapsular dissection in the parapharyngeal space: benefits and potential pitfalls.

The aim of this study was to investigate the benefits and potential pitfalls of transcervical extracapsular dissection in the treatment of parotid gland tumours in the parapharyngeal space. We retrospectively evaluated the records of all patients with parapharyngeal parotid gland lesions treated between 2000 and 2015 by transcervical extracapsular dissection. Patients having revision operations and patients whose records were not complete were excluded, leaving 49 patients in the study. We found acceptable oncological and functional outcomes throughout. Special attention should be paid in cases with multilobular growth of the tumour on magnetic resonance imaging, satellite tumours of pleomorphic adenomas, tumours in broad contact with the inner surface of the deep lobe, and lesions suspected of malignancy. Extracapsular dissection in the parapharyngeal region is associated with acceptable oncological and functional outcomes. These outcomes can be expected only after a thorough assessment of patient's history and preoperative imaging.

[Imaging of the head and neck region]. / Bildgebung der Kopf-Hals-Region.

Tumors of the head and neck are predominantly squamous cell carcinomas and those of the salivary glands are predominantly adenocarcinomas, adenoid cystic carcinomas and mucoepidermoid carcinomas. In 2011 the incidence of tumors of the oral cavity and pharynx in Germany was 6839 (5026 male and 1813 female) and of the larynx 1878 (1642 male and 236 female). The incidence of tumors of the nose and paranasal sinuses (467) and salivary glands (470) were much lower (www.krebsdaten.de/abfrage). The primary aim of imaging in head and neck cancer is staging of the disease and a precise assessment of tumor invasion. This information is essential for therapy decision-making (i. e. surgery or radiochemotherapy), planning of the extent of resection and subsequent reconstructive measures and also estimation of functional deficits after therapy. Computed tomography (CT) and magnetic resonance imaging (MRI) are the imaging modalities of choice but both have specific advantages and disadvantages. In certain cases both CT and MRI need to be performed for accurate treatment planning.

[Imaging of the head and neck region]. / Bildgebung der Kopf-Hals-Region.

Tumors of the head and neck are predominantly squamous cell carcinomas and those of the salivary glands are predominantly adenocarcinomas, adenoid cystic carcinomas and mucoepidermoid carcinomas. In 2011 the incidence of tumors of the oral cavity and pharynx in Germany was 6839 (5026 male and 1813 female) and of the larynx 1878 (1642 male and 236 female). The incidence of tumors of the nose and paranasal sinuses (467) and salivary glands (470) were much lower ( www.krebsdaten.de/abfrage ). The primary aim of imaging in head and neck cancer is staging of the disease and a precise assessment of tumor invasion. This information is essential for therapy decision-making (i. e. surgery or radiochemotherapy), planning of the extent of resection and subsequent reconstructive measures and also estimation of functional deficits after therapy. Computed tomography (CT) and magnetic resonance imaging (MRI) are the imaging modalities of choice but both have specific advantages and disadvantages. In certain cases both CT and MRI need to be performed for accurate treatment planning.

Assessing quality of life in patients after partial laryngectomy.

BACKGROUND: In the present prospective cross-sectional clinical study, correlations between global quality of life (QoL) and coping strategies were examined in patients who had undergone partial laryngeal resection for T1-T2 laryngeal cancer.  METHODS: Correlations between point scores in the "Trier Illness Coping Scales" and SF-36 were analysed in 71 patients (65 males, 6 females, mean age 62 years) at routine follow-up visits by means of linear regression and Pearson's R. RESULTS: The most important coping strategy was "threat control", followed by "search for social integration". Greater expression of "rumination" was statistically correlated with poorer quality of life, and patients with more advanced disease were more inclined to seek social integration. CONCLUSIONS: Coping strategies exert substantial influence on the quality of life of cancer survivors. Disease- or treatment-related day-to-day problems and anxieties about the oncological outcome have a greater influence on the quality of life of laryngeal cancer survivors than do voice changes. This finding should be taken into account in survivorship care planning.

[The significance of extracorporeal shock wave lithotripsy in sialolithiasis therapy]. / Der Stellenwert der extrakorporalen Stosswellenlithotripsie bei der Therapie der Sialolithiasis.

INTRODUCTION: Extracorporeal shock wave lithotripsy (ESWL) is now judged alongside other therapeutic alternatives like salivary gland endoscopy (SGE). The present analysis investigates the significance of ESWL within the scope of a defined treatment algorithm. METHODS: A retrospective analysis of data obtained between 2003 and 2009. The results were analysed according to the therapeutic modality used. Successful treatment was defined as an absence of symptoms or stones at follow-up examination. RESULTS: During the period studied, 206 patients with parotid stones and 736 with submandibular stones underwent treatment. Among the latter group, 5 % were treated exclusively by SGE, 92 % underwent transoral stone removal and 3 % received ESWL. The long-term success rates were 93 %, 90 % and 94 %, respectively. Patients with parotid stones were treated in 78 % of cases by ESWL and 22 % underwent SGE exclusively. The overall long-term success rates here were 85 % and 98 %, respectively. CONCLUSION: ESWL remains an important therapeutic tool in the management of sialolithiasis. The method is particularly important as a gland-preserving tool in the therapy of parotid stones and selected cases of submandibular stones, even though it is not available in the US due to the lack of official equipment approval.