[Diagnoses of thyroid disorders in ENT and general practices in Germany between 2008 and 2016]. / Diagnosen von Schilddrüsenerkrankungen in HNO-Praxen und Hausarztpraxen in Deutschland 2008­2016.

OBJECTIVE: The aim of this study was to investigate thyroid disorder diagnoses in otorhinolaryngologic (ENT) practices in Germany compared to general (GP) practices using data from a representative Germany-wide practice database. METHODS: The database was retrospectively searched for diagnoses of thyroid disorders made in ENT and GP practices between January 2008 and December 2016. Data were collected on the most common three-character disease classes (categories) from the "Disorders of thyroid gland" (E00-E07) group as well as the "Benign neoplasm of thyroid gland" (D34) and "Malignant neoplasm of thyroid gland" (C73) categories. The periods 2008-2010, 2011-2013, and 2014-2016 were evaluated. RESULTS: The database included 71 ENT and 506 GP practices with continuous participation from 2008 to 2016. The relative frequency (patients/practice) of diagnoses from the "Disorders of thyroid gland" group was 4.4-times higher in GP than in ENT practices. The relative frequency of benign neoplasms of the thyroid gland was 5­times higher in GP than in ENT practices. The relative frequency of malignant neoplasms of the thyroid gland was almost identical in GP and ENT practices. The most frequent diagnoses in both ENT and GP practices were found in the categories "Other nontoxic goiter" (E04) and "Other hypothyroidism" (E03). Diagnoses in the categories "Hyperthyroidism" (E05) and "Thyroiditis" (E06) were less frequent. Diagnoses of thyroid neoplasms were the least frequent, with benign neoplasms diagnosed more frequently in GP practices and malignant neoplasms diagnosed more frequently in ENT practices. During the study period, the diagnostic frequency of thyroid diseases decreased in ENT practices, whereas it increased in GP practices. CONCLUSION: Despite the increasing interest in establishing thyroid surgery in ENT clinics in Germany in recent years, thyroid diagnoses in ENT practices in Germany have been continuously declining, whereas they have considerably increased in GP practices. The reason for this may be health insurance provider-related differences in reimbursement practices for GPs and specialists.

Risk factors for epistaxis in patients followed in general practices in Germany.

BACKGROUND: The goal of the present study was to analyze the risk factors for epistaxis in patients followed in general practices in Germany. METHODS: The current study sample included patients aged 18 years or older who received a first epistaxis diagnosis between January 2012 and December 2016 (index date). Epistaxis patients and controls without epistaxis were matched (1:1) on the basis of age, gender, insurance status and physician. RESULTS: A total of 16,801 patients with epistaxis and 16,801 control subjects were included in this study. Of the subjects, 53.2% were men, and the mean age was 59.6 years (SD=21.2 years). Epistaxis was found to be positively associated with hypertension, obesity, chronic sinusitis, other disorders of the nose and nasal sinuses, anxiety disorder, and adjustment disorder (ORs ranging from 1.13 to 1.44). Epistaxis was also associated with the prescription of vitamin K antagonists, preparations from the heparin group, platelet aggregation inhibitors excluding heparin, direct thrombin inhibitors, direct factor Xa inhibitors, other antithrombotic agents, selective serotonin reuptake inhibitors and nasal steroids (ORs ranging from 1.15 to 3.55). CONCLUSIONS: Overall, epistaxis risk is increased by multiple medical and psychiatric disorders. Several antithrombotic and nasal steroid therapies are also associated with this risk.

Relevance of level I and IIB neck dissection in laryngeal cancer.

OBJECTIVES: Dissection of neck levels I and IIB is time-consuming and can cause comorbidity. This study aimed to determine whether level I and IIB neck dissection was necessary in patients with laryngeal cancer and clinically detectable or nondetectable neck nodes. PATIENTS AND METHODS: This was a retrospective review of 73 patients with laryngeal cancer. Essential clinical data were obtained and analysed to determine the incidence of neck node metastasis in levels I and IIB. RESULTS: Of the 48 patients with no clinically apparent neck nodes, none had level I metastases and only one had level IIB metastases. Of the patients with clinically detectable neck nodes, three of 21 patients had level I metastases and three of 25 patients had level IIB metastases; these six patients also had additional metastases in level IIA. CONCLUSION: Dissection of neck levels I and IIB is justifiable in laryngeal cancer patients with clinically detectable neck nodes and suspicious lymph nodes in the respective level or level IIA. However, in patients without clinically detectable neck nodes, preservation of levels I and IIB is oncologically safe, economical and reduces the risk of comorbidity.

[Significance of autopsy in patients with head and neck cancer]. / Stellenwert der Autopsie bei Patienten mit Kopf-Halstumoren.

BACKGROUND: Nowadays, the morphological assessment of samples obtained from living patients has a greater importance than the scientific knowledge which is gained by autopsy. Therefore, the aim of the study was a retrospective analysis of causes of death in patients with head and neck cancer. MATERIAL AND METHODS: The autopsy rate, clinical parameters of oncologic patients as well as autopsy findings like lethal complications, distant metastases and second primary tumors were retrospectively analyzed. RESULTS: From 1968 to 2007 in 91 patients with malignant tumors of the head and neck an autopsy was performed. In these 39 years an autopsy was performed in 45.9% of dead oncologic patients. Autopsy findings revealed distant metastases in 46.2% and second primary tumors in 17.6% of the patients. 49.5% of the patients died from pneumonia, 20.9% from tumor bleeding and 10% from progressive cachexia. CONCLUSION: The study confirms the global trend of a decline in autopsy numbers in the last 3 decades. However, as an important instrument of quality assurance autopsies continue to play an essential and indispensable role in medical research.

Lymphatic malformations involving the parotid gland.

INTRODUCTION: Cases of salivary gland involvement of lymphatic malformations have been occasionally reported in the literature. Of all the lymphatic malformations in the salivary glands, the parotid is the most common site. The present study aimed to analyze a series of lymphatic malformations of the parotid gland. MATERIALS AND METHODS: A retrospective analysis of the localization, symptoms, management and outcome was performed. RESULTS: Out of a total of 20 patients with lymphatic malformations of the parotid gland, 4 patients suffered from lymphatic malformations limited to the parotid gland (type I) and 16 patients from extensive cervicofacial lymphatic malformations involving the parotid gland (typeII). In 2 cases with type I disease and 4 cases with type II disease the malformations could be completely resected. In 3 patients with type II lymphatic malformations a partial resection was performed. The other patients were closely observed. 8 of them had already been treated elsewhere with surgery, sclerotherapy or laser therapy. One patient suffered from facial paralysis and 1 from transient facial nerve weakness immediately after surgery. In all, 11 patients suffered from persistent lymphatic malformations despite several attempts to reduce or resect the lymphatic malformation. CONCLUSION: The treatment of lymphatic malformations of the parotid gland remains challenging and persistent disease after therapy is common. Care should be taken to excise the entire malformation during initial surgery in order to avoid recurrence.

Wyburn-Mason syndrome: a case report.

OBJECTIVE: Wyburn-Mason syndrome is a rare disease associated with multiple arteriovenous malformations of the brain, orbit, and face resulting from an insult occurring during embryonic development. CASE REPORT: We present the clinical and radiological features of a 47-year-old-man with Wyburn-Mason syndrome who suffered from recurrent bleeding episodes primarily at the nasal corner of the left orbit. After radiotherapy and several angioembolisations, surgical reduction with exenteration of the left orbit was performed and resulted in reduced bleeding. Two years later the patient presented with maxillary sinus empyema. Due to massive endonasal bleeding, endoscopy could not be performed and the maxillary empyema was treated via a transorbital approach. CONCLUSION: Although close observation represents the standard of care in Wyburn-Mason syndrome, patient-specific management decisions are required in the presence of symptoms or complications. In the presented case, surgical intervention proved to be successful.

Analysis of clinically suspected orbital cavernomas.

BACKGROUND: Orbital cavernomas are low-flow vascular malformations that are the most common benign neoplasms of the orbit in adults, typically becoming symptomatic in the middle age. METHODS: The medical records of six patients with clinically suspected orbital cavernomas receiving elective surgical excision were analysed concerning symptoms, physical findings, treatment results and visual outcome. The pathologic slides were evaluated, and additional immunohistochemical stains were done if necessary to obtain diagnosis. RESULTS: Histologic evaluation revealed three of six cases not being cavernomas, although the clinical and macroscopic findings were consistent with orbital cavernomas. Two of them were haemorrhagic lymphangiomas, and one was a solitary fibrous tumour. CONCLUSIONS: Haemorrhagic lymphangiomas and other vascular tumours may mimic orbital cavernomas regarding anamnesis, radiologic and intraoperative findings and gross examination. Therefore, exact histologic evaluation is necessary to get the correct diagnosis.

Post-tonsillectomy pseudoaneurysm: an underestimated entity?

OBJECTIVE: To identify patients undergoing arteriography to verify vascular complications of tonsillectomy, with an emphasis on pseudoaneurysm. PATIENTS AND METHODS: We undertook a retrospective analysis of the case records of 8837 patients who had undergone tonsillectomy between 1988 and 2004 at our institution, together with a review of expert reports written for professional boards and civil courts as well as personal experiences or communication. We also conducted a literature review using the PubMed database. RESULTS: We identified seven cases with vascular abnormalities. In addition, we identified three cases of pseudoaneurysm formation, involving two children and one adult patient, with bleeding 21, 36 and 58 days after tonsillectomy. Successful management included embolisation (two patients) and revision surgery (one patient). CONCLUSION: Post-tonsillectomy pseudoaneurysm formation is extremely rare and unrestricted by age. Correct diagnosis depends largely on a high index of clinical suspicion. Delayed and repeated episodes of gushing haemorrhage with spontaneous cessation appear to be a significant clinical marker. Immediate arteriography, with simultaneous embolisation, is highly recommended. The lingual artery is the most commonly involved vessel.

Digital volume tomography in the diagnosis of nasal bone fractures.

Digital volume tomography (DVT) is a kind of cone beam computed tomography and enables high quality 3D images of osseous structures. It is a well-established diagnostic tool in dentistry. High detail resolution is reached with a reduced exposition of radiation dose in comparison to conventional computed tomography. The data volume can be analysed in three orthogonal plains, which can be changed in angle arbitrarily. The aim of the study was to evaluate, if and in which performance DVT is able to detect discrete nasal bone fractures that cannot be seen in conventional radiography occasionally. DVT was performed in sixty-five patients with suspected nasal bone fracture. Five of these patients underwent lateral radiographs of the nasal bones in other departments which failed to show any radiologic signs of a nasal bone fracture, whereas DVT showed clear fracture lines. DVT-findings were also used to classify fractures according to their dimensions. Additionally DVT enabled the reconstruction of three-dimensional volume images. With this technique it is possible to get an image of the extent of the nasal bone fracture and the dislocation of the fragments. Because of these facts as well as its high resolution and low radiation dose, DVT can be recommended as the routine radiological examination in suspected nasal bone fractures.

Prospective study on neck dissection after primary chemoradiation therapy in stage IV pharyngeal cancer.

BACKGROUND: Definitive chemoradiation is a well-established option in the treatment of locally advanced squamous cell carcinoma of the head and neck. The intention of this study was to evaluate its efficacy on cervical lymph node metastases in a prospective study after a standardized protocol for chemoradiation (CRT) and histopathological evaluation, respectively. PATIENTS AND METHODS: The data of 25 patients (10 oropharynx, 15 hypopharynx) who received planned neck dissection after definitive chemoradiation for UICC stage IV carcinomas of the pharynx were analyzed. All patients were sonomorphologically staged positive for lymph nodes (3 patients: N1; 2 patients N2a; 7 patients N2b; 9 patients N2c and 4 patients N3). A neck dissection was carried out 8.9+/-1.5 weeks (range 6-13) post treatment. The specimens obtained from the different neck levels were histologically examined for viable tumour cells. RESULTS: Local control was achieved in 100% of all patients on endoscopy 9 weeks after the chemoradiation. In 14/25 patients (56%), still viable tumour tissue was found in the neck dissection (ND) specimen. Only one of these 14 patients (7%) was deemed suspicious for residual lymphadenopathy from clinical and diagnostic findings at re-staging after chemoradiation, the others were staged yN0. Postsurgical complications occurred in six patients (24%) such as bleeding and prolonged wound healing in one patient each and functional deficits in an additional four patients. One patient developed a scar recurrence seven months after surgery. CONCLUSION: Based on these findings, the ultimate efficacy of primary CRT should not be judged 8-10 weeks after the treatment. Therefore planned neck dissection should be performed no earlier than 12 weeks after primary CRT.

[Nasal bone fracture: etiology, diagnostics, treatment and complications]. / Die Fraktur des Os nasale: Unfallmechanismen, Diagnostik, Therapie und Komplikationen.

BACKGROUND: The aim of the present evaluation was to analyse a large patient population with nasal bone fractures leading to surgical reposition of the nasal bone. Special attention was paid to age summit, the distribution of the seasons, the rate of open compared to closed nasal bone fractures, accompanying injuries, diagnosis and therapy as well as to the postoperative course. METHODS: A total of 300 patients was evaluated retrospectively. All patients had been treated between 1999 and 2004 regarding simple and complex nasal bone fractures. Data were analysed with regard to history, age, gender, diagnosis, therapy, results, and complications. RESULTS: The average age of the patients was 29.6+/-15.6 years at the time of fracture with clear predominance of the male gender (77%). Another age summit could be observed in patients of >60 years. The main reasons for nasal bone fracture were falls (30%), in elderly patients often caused by cardiac syncopes, and rows (28%). The most frequent findings were deviation of the longitudinal axis of the nose (59%) and traumatic deviation of the nasal septum (50%). 65 patients (22%) had open nasal bone fractures, in 5% of the cases septal hematoma could be observed. CONCLUSION: Closed reposition of the nasal bone is the therapy of choice in uncomplicated nasal bone fractures. Special attention has to be paid to the group of patients aged 60 years and older who often suffer from treatment requiring comorbidities. In these cases inpatient treatment must be considered.

Surgery in patients with vascular malformations of the head and neck: value of coagulation disorders.

OBJECTIVES: The surgical treatment of congenital vascular malformations always bears the risk of severe bleeding. The aim of this study was to investigate the prevalence of haemostatic abnormalities in patients with congenital vascular malformations of the head and neck which could additionally complicate the complex surgery of vascular malformations. METHODS: Thirteen patients with congenital vascular malformations of the head and neck, who underwent scheduled surgery, were reviewed regarding their haemostatic tests, including prothrombin time, activated partial thromboplastin time, fibrinogen level, platelet count, platelet function analyzer-epinephrine (PFA-Epi) and -adenosine diphosphate (ADP) (PFA-100), von Willebrand factor (vWF) and D-dimers. RESULTS: In six of 13 patients an impaired primary haemostasis was detected by prolonged PFA-Epi and one of these patients also had a slightly prolonged PFA-ADP. Additionally, two of the patients showed mild coagulation factor deficiency. One patient had a mild vWF deficiency that was not detected by PFA-100. CONCLUSION: Prior to surgery of congenital vascular malformations of the head and neck, a detailed coagulation analysis is needed in order to identify those patients at increased risk of bleeding. This proceeding is supported by the fact that a relevant portion of the patients with congenital vascular malformations of the head and neck show an impaired primary haemostasis.

[Current status of head and neck cancer therapy in the elderly]. / Therapie von Kopf-Hals-Karzinomen im fortgeschrittenen Lebensalter.

In the years to come health care systems of western industrialized nations are going to be increasingly faced with the results of demographic changes. Especially the part of elderly citizens will grow steadily. Thus, also an increasing number of malignant diseases not only in the head & neck area is expected. Decision-making in cancer therapy for elderly patients is challenging for medical professional since this subject is accompanied by a high rate of uncertainness. For fear of aggressive therapy regimens with subsequent increase of morbidity, in many cases only incomplete diagnostic and therapeutic measures are taken. Reviewing the literature there is almost complete international consensus, that patients suffering from squamous cell cancer of the head & neck should be treated with curative intention, if thorough preoperative assessment of present comorbidities is performed. Furthermore aggressive treatment options should not be excluded. An optimal medical adjustment of relevant concomitant diseases clearly improves the starting point. In comparison to younger control groups therapy associated complications do not occur significantly higher. For this reason elderly patients should be treated with curative intention. Age itself should never be a sole factor deciding which curative therapy should be undertaken. Exceptions could be made in patients with severe general comorbidity.

Early supraglottic cancer: how extensive must surgical resection be, if used alone?

OBJECTIVES: Two centre based evaluations of oncologic results of endoscopic resection of supraglottic cancer without post-operative irradiation. PATIENTS AND METHODS: Twenty-six patients with clinical T1 (n=5) or T2 (n=21) primary squamous cell carcinomas of the supraglottic larynx and with N0 (n=24) or N1 (n=2) neck disease were treated by endoscopic supraglottic laryngectomy coupled with neck dissection(s). Endoscopic resection was standardized whereas neck dissections (NDs) varied from classical modified radical ND to selective ND of levels I to IV. RESULTS: Pathologically, three T2 patients were upstaged to T3, four N0 patients to N1 and one N2 patient down-staged to N1. Within an average of 42 months, there were no local failures and only one regional failure. CONCLUSIONS: Endoscopic resection of T1 and T2 supraglottic cancer without post-operative irradiation achieved good oncological results. No patients with lateralized primary cancers were found to have contralateral cancer on pathological evaluation from bilateral dissections.

The status of neck node metastases in breast cancer--loco-regional or distant?

Metastases to cervical lymph nodes do not exclusively derive from malignancies of the head and neck area. In the literature the region where distant metastases of breast carcinomas to the neck occur is exclusively named "supraclavicular". The system established by head and neck surgeons regarding neck node topography allows interdisciplinary management of patients with cervical lymph node metastases from breast cancer. Twelve patients suffering from breast cancer who presented with cervical masses have been examined. Most lymph node metastases were found in the posterior triangle of the neck and at the caudo-jugular level, but some metastases were even found in the upper jugular levels. The results presented show that neck node metastases of breast cancer are located superiorly to the supraclavicular region in more than 50% of the cases. According to the AJCC Staging System for Breast Cancer metastases located in the supraclavicular fossa are assessed as loco-regional metastases (N3c). Lymph node metastases situated above the supraclavicular region are not mentioned, but should be considered as distant metastases. This important question remains unanswered and deserves clarification in the current classification of the AJCC Staging System for Breast Cancer.

Influence of matrix metalloproteinase 9 (MMP-9) on the metastatic behavior of oropharyngeal cancer.

BACKGROUND: The role of the single matrix metalloproteinases (MMPs) in the metastatic process of squamous cell carcinomas (SCC) is still obscure. MATERIALS AND METHODS: The MMP-9 expression was described immunohistochemically in 105 patients (40-79 years of age, mean: 57.84 years; 84 male, 21 female) suffering from orophatyngeal cancer (22x TI, 31x T2, 24x T3, 28x T4) with different neck stages (41x N0, 6x N1, 54x N2, 4x N3 neck). RESULTS: A significant correlation between MMP-9 expression and T stage (p < 0.05), N stage (r = 0.55, p < 0.01) and UICC stage (r = 0.55, p < 0.01) was revealed. Most remarkable was the high MMP-9 expression with simultaneously high UICC stages. CONCLUSION: The results give further indication that MMP-9 plays a role in the metastatic behavior of oropharyngeal SCC. It will be a project for the near future to create a standardized evaluation score of immuno-histological stainings to allow valid comparison of the results and published data.

Bipolar radiofrequency induced thermotherapeutic volumetric reduction of VX2 metastases in an animal model.

BACKGROUND: Radiofrequency-induced thermotherapy has shown promising results in the palliative treatment of various tumor entities. The purpose of this study was to investigate the effectiveness of bipolar radiofrequency volumetric tissue reduction (VTR) on lymph node (LN) metastases in the VX2 SCC model. MATERIALS AND METHODS: Six male New Zealand white rabbits, with palpable metastatic disease within the parotid lymph nodes, were treated using the Celon-ProSurge probe, needle length 10 mm, diameter of 2.3 mm. The animals were sacrificed on the 4th, 8th, 11th, 14th, 18th and 22nd postoperative days respectively. RESULTS AND CONCLUSION: Bipolar radiofrequency VTR could prevent progression of local metastatic disease in one-third of the animals compared to the control group of untreated VX2 carcinoma rabbits. These results encourage further studies, directed at whether this treatment modality could play a role in the palliative therapy of metastatic LN. Future studies should concentrate on the refinement of the treatment parameters and optimization of the treatment duration.

RT-PCR expression profiling of matrix metalloproteinases and their specific inhibitors in cell lines and fresh biopsies of squamous cell carcinomas of the head and neck.

The expressions of MMP2, -7, -9, -13 and TIMP1, -2, -3 were examined in biopsies and cell lines of head and neck squamous cell carcinomas (HNSCC) to determine the association between the expression profile and TNM-staging of the primary. The expressions of MMP2, -7, -9, -13 and TIMP1, -2, -3 were analyzed in 30 HNSCC biopsies, 7 HNSCC cell lines and 1 keratinocyte cell line using RT-PCR. Negative correlation was determined between N-status and MMP13-RNA expression [Kendall-tau-b -0.404 (p = 0.016), Spearman-rho -0.448 (p = 0.014)], histological grading [Kendall-tau-b -0.291 (p = 0.049), Spearman-rho -0,333 (p = 0.048)], and MMP7 and TIMP2 expression [Kendall-tau-b -0.318 (p = 0.045); Spearman-rho -0.353 (p = 0.045)]. Positive correlation was determined between M-status and MMP9-RNA expression [Kendall-tau-b 0.341 (p = 0.025), Spearman-rho 0.377 (p = 0.024)] and MMP13 and TIMP2 expression [Kendall-tau-b 0.727 (p = 0.037), Spearman-rho 0.850 (p = 0.016)]. The results point to a role of the tested MMPs and TIMPs in the metastatic spread of HNSCC.

Variations of EGF-R surface expression in squamous cell carcinomas of the head and neck region.

BACKGROUND: It has been previously found that the epidermal growth factor receptor (EGF-R) is highly expressed in squamous cell carcinomas of the head and neck region (SCCHN) and that this expression correlates with malignant transformation and tumor development. MATERIALS AND METHODS: We examined 9 SCCHN cell lines and a control keratinocyte cell line for EGF-R expression, utilizing fluorescence-activated cell sorting (FACS) and Western blot analysis. Immuno-cytochemistry was performed to evaluate the receptor's cellular distribution. RESULTS: We found the EGF-R to be up-regulated in SCCHN. Surprisingly we did not see a clear correlation between tumor staging, grading or Stat3 signaling and EGF-R level but we observed up to three distinct EGF-R specific bands in our Western blots, implicating the presence of different protein isoforms. CONCLUSION: Our data suggest that not only the amount but also the receptor function, including the presence of mutations, need to be considered in SCCHN malignancies.