[Transoral resection of locally advanced squamous cell carcinoma of the lateral oropharynx: combination of CO2 laser microsurgery with flap reconstruction]. / Transorale Resektion lokal fortgeschrittener Plattenepithelkarzinome der Oropharynxseitenwand: Kombination der CO2-Lasermikrochirurgie mit einer primären Defektdeckung.

INTRODUCTION: Transoral laser microsurgery of locally advanced carcinomas of the lateral pharynx often results in exposure of major vessels of the neck and is accompanied by a substantial risk of intra- and postoperative bleeding. We therefore only perform these operations after external protection of neck vessels, if necessary combined with flap reconstruction. PATIENTS AND METHODS: Between October 2001 and December 2004, 11 locally advanced squamous cell carcinomas of the lateral oropharynx that reached the major vessels of the neck were treated as follows: after ipsilateral neck dissection with temporary protection of the jugular vein and carotid arteries, the neck remained open while transoral laser surgery of the primary tumor was performed. Pharyngeal defects were subsequently closed by either primary suture or a platysma myofascial flap. All patients underwent adjuvant radiotherapy. RESULTS: All primary tumors were completely resected. None of the patients required tracheotomy or placement of a percutaneous endoscopic gastrostomy tube. The mean duration of nasogastric feeding tubes was 12.7 days. In one case, the routine radiological contrast study revealed a blind cervical fistula 10 days after surgery. This healed spontaneously within 7 days. One mild postoperative hemorrhage had to be stopped by endoscopic coagulation under general anesthesia. During a mean follow-up of 19.4 months, none of the patients developed a local and/or regional recurrence. CONCLUSION: The surgical procedure described ensures sufficient protection of neck vessels during and after the transoral resection of advanced carcinomas of the pharynx. It successfully combines the advantages of minimally invasive laser microsurgery with those of flap reconstruction known from traditional surgery.

[Chronic back pain and expert opinion]. / Der chronische Rückenschmerz und seine Begutachtung (I).

Back pain, especially chronic back pain, is not only a medical and psychological burden but also an economic problem due to the extremely high associated costs. These are generated by treatment and rehabilitation measures, pensions and loss of working hours. The cause of pain is multifocal and frequently remains unclear. It is not the etiology of back pain that has changed in the last 20 years, but its rate of assessment and treatment options. According to the relevant literature, treatment of chronic back pain will most probably only succeed using multimodal concepts that have to consider medical/somatic and psychosocial aspects and be based on scientific training experience. Pain assessment is based on common legal and certification standards. However, typical decision and rating problems result from the difficulty of objective medical registration and grading of pain. Medical certification may often be complicated by co-morbidities such as somatic pain attacks, fibromyalgia, depression or anxiety. These cases necessitate close cooperation with other medical specialities.

[Tonsillectomy by CO@ laser microsurgery--an analysis of clinical and morphological data]. / Die mikrochirurgische Tonsillektomie mit dem CO2-Laser. Eine Analyse klinischer und morphologischer Daten.

BACKGROUND: Tonsillectomy by CO(2) laser microsurgery is an almost bloodless procedure that has developed to an alternative to traditional dissection tonsillectomy during recent years. It has been suggested that the laser technique more precise than the conventional one, however, attempts to investigate this morphologically have not yet been undertaken. In addition, there is a need for large clinical studies to compare the postoperative bleeding risk of both procedures. METHODS: The charts of 617 patients who underwent routine tonsillectomy between 1995 and 1998 at the ENT department of Darmstadt Hospital, were retrospectively investigated with regard to postoperative bleeding events. A total of 467 patients were treated by the conventional technique and 150 by CO(2) laser microsurgery (continuous mode, 5 W). Moreover, 2 mm serial sections of tonsils of 56 consecutive patients treated in 1999 (31 conventional and 25 laser tonsillectomies) were used to determine peritonsillar (Vp) and tonsillar tissue volumes (Vt). RESULTS: The postoperative bleeding risk following laser tonsillectomy differed slightly from that following the conventional technique (12.0% vs 14.6%; P=0.499; Fisher's exact test). However, the incidence of severe bleeding events requiring revision in general anesthesia was significantly reduced (0.7% vs 4.9%; P=0.015; Fisher's exact test). Tonsillar specimens that were removed by laser surgery contained significantly less peritonsillar tissue than those from conventional procedures (Vp/Vt 5.1%+/-0.6% vs 10.8%+/-1.1%; P below 0.001; Mann-Whitney U-test). CONCLUSION: CO(2) laser microsurgery improves the precision of tonsillectomy and provides a maximum protection for the peritonsillar tissue. The incidence of severe bleeding events is markedly reduced. Laser tonsillectomy is therefore recommended for patients with clotting disorders or those requiring a particularly exact preparation technique.

[The placebo trap]. / Die Plazebofalle. Sind wir ein Volk von Blockierten?

Monodisciplinary orthopaedic pain therapy no longer measures up to international standards. In cases of chronic back pain, in particular, there is such a gulf between the clinical findings and the patient's subjective assessment that the symptoms cannot be attributed solely to so-called degenerative changes. Back pain patients are in great danger of becoming fixated on somatic symptoms due to an excess of diagnostic procedures or incorrect diagnoses, of being treated purely somatically on the basis of associated findings, and of suffering irreversible damage from invasive management of such findings. Despite the wealth of empirical evidence, it remains difficult to expand the everyday concept of illness and its causes to include not only physical and biological factors but also social and emotional disturbances. Particularly physicians with a purely biological concept of pain have not learned to take note of affective relational factors and incorporate them into their diagnostic assessment. The decision to undertake invasive diagnostic or therapeutic procedures then frequently represents the doctor's reaction to feelings of irritation or helplessness. If this situation is to change, an interdisciplinary concept of pain must be made a part of medical training, and scientific findings must be presented in such a way that they can be integrated into routine daily practice.

[Duplex ultrasound control of the effectiveness of a newly developed combined pressure clamp for acute and long-term pressure dressings of the femoral artery and vein after heart catheterization]. / Duplexsonographische Effektivitätskontrolle einer neuentwickelten Kombination aus Druckpresse zur Akutkompression und Dauerkompressionsverband von A. and V. fermoralis nach Herzkatheterismus.

After transfemoral angiography the artery has to be manually compressed in order to stop acute bleeding. Then, to prevent retarded bleeding, a continuous pressure dressing has to be fixed for up to 24 h. To simplify this procedure, we developed a novel compression device and tested it in 133 patients. Color-flow-ultra-sonography was used to scan gross alterations such as hematomas, AV-fistulas or pseudoaneurysms, and changes in tissue consistency as well. By the new device it is possible to perform femoral artery compression and to substitute pressure dressing safely and with significantly less expenditure than by the combination of manual compression and pressure dressing. We found a reduction from 18 to 3 min time requirement for primary sealing of the puncture site. Moreover, 86% of patients experienced in both methods--the conventional and the new device--would prefer the new equipment in recatheterization. It is better tolerated than the combination of pressure dressing and manual compression. The device is reusable and the compression is easily and exactly adjustable in a wide pressure range. In comparison with previously described mechanical compression systems the remarkable advantage of our device is to merge the function of compression for sealing of the puncture site and pressure dressing for prevention of retarded bleeding.

[Calcium phosphates in otologic surgery. III. The role of fibrin glue in the integration of calcium phosphate implants. Experimental study]. / Fosfatos cálcicos en la cirugía otológica. III. El papel de la cola de fibrina en la integración de implantes de fosfato cálcico. Estudio experimental.

Obliteration of the mastoid cavity has been realized with calcium phosphates associated to heterologous fibrin glue in otologic surgery. 22 artificially created epitympanic and 65 femoral defects in 22 rabbits were closed by means of dense or porous granulates of hydroxyapatite with homologous fibrin glue. Follow-up was for three weeks to 6 months. Osteo-integration of the implants was significantly delayed in the first weeks, comparing the integration of the same phosphates without fibrin glue.

[Calcium phosphates in otological surgery. II. The bony integration of calcium phosphates. An experimental study]. / Fosfatos cálcicos en la cirugía otológica. II. La integración ósea de implantes de fosfato cálcico. Estudio experimental.

Calcium phosphates have been proposed for obliteration of the mastoid cavity as well as TORP and PORP. Their use is based on a very good biocompatibility and host acceptance. The osseous integration of a dense and a porous hydroxyapatite is studied experimentally in artificially created epitympanic holes of rabbits. Osteoneogenesis was observed from the third week after surgery starting from the walls od the defects themselves. This had been evidenced using intravital fluorescent dyes. Porous granules showed more "osteoconductivity" in the beginning, probably due to their greater surface area. Bonding osteogenesis with both materials did not show differences after six months. No resorption was observed, excepting remodelation processes.

[Calcium phosphates in surgery of the middle ear. I. The concepts and definitions]. / Fosfatos cálcicos en la cirugía de oído medio. I. Conceptos y definiciones.

The techniques which pursue the closure of radical cavities include the use of local flaps as well as alloplastic material. Calcium phosphates are classified as "degradable" or "not degradable". The paper tries to offer an explanation why hydroxyapatite or tricalcium phosphate, mostly used calcium phosphates, may be include in both groups. The introduction in the use of alloplastic materials should serve as orientation for those who initiate and stimulate to revision of clinical results. The comparison of same calcium phosphates seems not to be possible as their preparation techniques may be completely different.

[Endonasal, endoscopic-microscopic control of the decompression of the optic nerve. An anatomic endoscopic presentation of the operation]. / Die endonasale, endoskopisch-mikroskopisch kontrollierte Dekompression des N. opticus. Eine anatomisch-endoskopische Darstellung der Operation.

The indication for decompression of the optic nerve after indirect trauma is made both by the ophthalmologist and the ENT-surgeon. The ENT-surgeon usually reaches and decompresses the optic canal by a transethmoidal-transsphenoidal route. The majority of authors prefer the transfacial approach to the ethmoid including resection of the crossing plane comprising the frontal process of the maxilla, the ethmoid, the lacrimal and the frontal bone. Hitherto we have knowledge of only one author utilising an endonasal approach to decompress the optic nerve. At the university hospital of Göttingen, the ENT-surgeons gathered experience with the endonasal, endoscopically and microscopically controlled operation method, which is less traumatic to the patient and avoids postoperative mucoceles of the frontal sinus. This surgical procedure is described by surgical-anatomical specimens.

[Reoperations in otosclerosis. Indications, intraoperative findings, and results]. / Las reintervenciones en la otosclerosis. Indicaciones, hallazgos intraoperatorios y resultados.

The audiological outcome of 140 stapedectomy revisions done between 1977 and 1987, as well as the pre- and intraoperative findings and the subjective appraisal of the revisions, are presented. The recurrence of the conductive deafness was the most often indication for the surgical revision and the shift of the prosthesis, verified intraoperatively, the most encountered finding. Audiological results showed, as mean value, an important reduction of the transmissive hearing loss whilst the bone conduction remained unaltered. Patients' subjective evaluation of the results were worse than audiometric controls. From the retrospective study of these 140 revisions the AA' experience is that the stapedectomy revision offers no major risk for the inner ear.

[Therapy of ozena]. / Zur Therapie der Ozaena.

This paper reports on surgical therapy of ozena. Hydroxylapatite was implanted under the mucosa of the nasal septum and the floor of the nasal cavity in four patients with ozena. In five patients the nostrils were totally closed by the method of Young. After a period of 2 to 5 years, the clinical results in both groups enable us to recommend both surgical procedures.

Bisoprolol pilot studies in myocardial infarction.

The efficacy of beta-blockade after myocardial infarction (MI) has been investigated in a series of studies. When beta-blockers are used during the first hours after the onset of MI, a reduction in infarct size, mortality, and nonfatal reinfarction may occur. Bisoprolol is a highly beta1-selective beta-blocker, without intrinsic sympathomimetic activity (ISA), and with a plasma elimination half-life of 10-12 h, permitting treatment with one daily dose. Because no experience with bisoprolol was available in MI, its safety and efficacy were studied in two open, uncontrolled pilot studies. The first study was a dose-finding study in 37 patients with a 3-day-old MI. Bisoprolol was given intravenously and carefully titrated in steps of 1 mg up to a cumulative maximum dose of 5 mg. Subsequently, the patients received 10 mg of oral bisoprolol once daily (o.d.) until the end of the study. Based on the results of this first pilot study, a second pilot study was performed in which bisoprolol was given within the first 6 h after the onset of MI. Intravenous (i.v.) bisoprolol was titrated in two steps of 2.5 mg each, directly followed by 10 mg of oral bisoprolol o.d. The aim of this study was to investigate the influence of i.v. and subsequent oral bisoprolol on central hemodynamics. The results of these studies demonstrate that i.v. and subsequent oral administration of bisoprolol is well tolerated and indicate that the selected dose regimen is hemodynamically safe.

[Keratocysts of the maxilla and zygoma. Case report and review of the literature]. / Keratozysten des Oberkiefers und des Jochbeins. Fallvorstellung und Literaturübersicht.

Keratocysts are a special entity of jaw cysts. The horizontal and distal regions of the mandible and the ascending ramus of the mandible are the most common locations of these cysts. Keratocysts of the os zygomaticum and orbital floor are extremely rare. In case of infection radiologic and histologic diagnosis are difficult and these cysts are often misdiagnosed as radicular and follicular cysts. The case of a 49-year old man is reported, who was admitted to hospital suffering from recurrent episodes of maxillary sinusitis with orbital involvement. He had previous sinus surgery six times. The clinical, histologic and radiologic characteristics are reported. In a literature review the present case is discussed. Because the recurrent-rate of keratocysts is rather high, complete removal and careful post-operative follow-up are mandatory.

[Fibrin glue and tricalcium phosphate implants in middle ear surgery. An animal experiment study]. / Fibrinkleber und Tricalciumphosphat-Implantate in der Mittelohrchirurgie. Eine tierexperimentelle Studie.

Tricalcium phosphate (TCP) with and without heterologous fibrin glue has been used for obliteration of the mastoid cavity in middle ear surgery. The use of TCP with a homologous fibrin glue has not been described so far. Obliteration of 22 epitympanic and 51 femoral defects in rabbits by means of TCP-granulates without and with homologous fibrin glue was performed in 18 animals. Follow-up was for 2 weeks to 6 months. Histological osteo-integration was studied microscopically. Fibrin glue induces the development of soft tissue impeding osseous integration of the calcium phosphate for at least 6 weeks.

[The effect of fibrin glue on the healing of hydroxyapatite ceramics. An animal experiment study]. / Der Einfluss von Fibrinkleber auf die Einheilung von Hydroxylapatit-Keramik. Eine tierexperimentelle Studie.

Calcium phosphate ceramics have been proposed for obliteration of the mastoid cavity in middle ear surgery. To our knowledge no experimental data are available concerning the use of homologous fibrin glue associated with hydroxyapatite (HA) in animals. Obliteration of the epitympanic space and closure of defects in the femur of rabbits by HA granules with and without homologous fibrin glue were performed on 17 animals, and the animals followed up for 2 weeks to 6 months. X-ray and histological examinations of the tissue integration of the implants were performed by semi-quantitative measurements. Fibrin glue accelerates the development of soft tissue and slows down the osteointegration of the ceramic implants.

Bioactive glass-ceramics in middle ear surgery. An 8-year review.

An 8-year follow-up of Ceravital middle ear prostheses showed there was extremely good tolerance in the middle ear space. Incompatibility phenomena were not observed, and inflammatory reactions were neither caused nor supported by the implants. The tympanoplasties were always performed without interposition of cartilage between the tympanic membrane or the tympanic membrane graft and the disk-shaped portion of the implant, and extrusions were never observed. Long-lasting inflammatory processes appeared to destroy implants the same way they destroy ossicles. Transient inflammatory periods (such as episodes of purulent otitis media, which occurred soon after the prostheses were implanted) did not lead to any remarkable changes of the surface of the implant. In healthy middle ears, the hearing results were stable.