[Tonsillectomy for MRSA eradication-a case report]. / Tonsillektomie zur MRSA­Sanierung ­ eine Kasuistik.

Herein is reported the case of a clinician in whom, after three unsuccessful attempts to eradicate a nasopharyngeal MRSA (methicillin resistent staphylococcus ausreus) colonization, tonsillectomy was performed with long-term success.

[Histology after adenoidectomy/tonsillectomy? No conformity in Germany concerning the histopathological examination of adenoids or tonsils in children up to the age of 10 years]. / Histologie nach Adeno-Tonsillektomie? In Deutschland kein einheitliches Vorgehen bei Patienten bis zum Alter von 10 Jahren.

BACKGROUND: It is more and more doubted that adenoids or tonsils have to be examined histologically in pediatric cases, in which history and clinical signs and symptoms are conclusive for chronic inflammation or hyperplasia. It is unknown whether there is any conformity about this question in Germany. METHOD: The heads of all clinical departments of otorhinolaryngology (n=149) and a similar number of ENT specialists from the Berufsverband Deutscher HNO-Arzte (n=150) were surveyed by a simple questionnaire. They were asked if they would routinely send resected tissue for histopathological examination in the case of a child, up to 10 years old, presenting with a history and a status of chronic inflammation or hyperplasia and undergoing adenoidectomy or tonsillectomy. Furthermore they were asked whether they remembered any unusual or surprising report in this group of patients. RESULTS: Feedback was 79%. All tissue was sent for examination by 59% of the colleagues answering this evaluation; palatine tonsils only were sent for examination by 14%, and 27% of the physicians did not send any tissue for histological work-up. During their professional career 17% of the responding ENT specialists had received a surprising result from the histopathological examination. CONCLUSION: We do not have any consensus practiced in Germany concerning the necessity to send tissue for histopathological examination following adenoidectomy or tonsillectomy in children. It seems helpful to seek such consensus of opinion for medicolegal and socioeconomic reasons.

[Histological examination following adenoidectomy and tonsillectomy in children. Surprising results are very rare]. / Histologische Untersuchung nach Adenotomie und Tonsillektomie bei Kindern. Nur selten findet sich ein überraschender Befund.

BACKGROUND: The histological examination of lymphatic tissue resected in children during adenoidectomy or tonsillectomy has to be considered as a screening method. Its purpose is to detect rare diseases that differ from "chronic inflammation" or "lymphatic hyperplasia". That this examination is economically reasonable in relation to the frequency of surprising results with therapeutic consequences is doubtful. The aim of this study was to define the frequency of surprising or clinically relevant results in histological reports following adenoidectomy and/or tonsillectomy in children. METHODS: From both 1999 and 2004, 200 patients were identified, 10 years old or less, who underwent adenoidectomy/tonsillectomy due to recurrent throat infections or stenotic symptoms of the upper airways or upper swallowing path. The histological reports on these 400 children were evaluated. RESULTS: At the date of surgery, the median age was 4 years. In 140 children, an adenoidectomy-tonsillectomy was performed, 26 underwent tonsillectomy alone and 234 adenoidectomy alone. No reports with a histological diagnosis other than "lymphatic hyperplasia" or "chronic tonsillitis" were found. DISCUSSION: A histological report that is surprising or might influence the further treatment of the patient is rare. From the literature, an unusual diagnosis in children occurs in less than 1 per 1,000. The routine histological examination of adenoidectomy/tonsillectomy tissue cannot nowadays be economically justified. On the other hand, the ethical aspects of the abolition of this inefficient but established method should be discussed. If routine histological examination is abandoned, the surgeon would be responsible for the decision of whether a histological examination is necessary for each individual case (asymmetry of tonsils, extraordinary cervical lymph node status, striking history e.g.).

[Histological criteria and metastasis of squamous cell carcinoma of the pinna]. / Histologische Kriterien und Metastasierungshäufigkeit von Plattenepithelkarzinomen der Ohrmuschel.

INTRODUCTION: According to the guidelines for cancer of the skin in the head and neck region of the German association of Otolaryngology, Head and Neck surgery squamous cell carcinoma (SCC) of the pinna are classified by using the current TNM system of skin cancer. As soon as cartilage is infiltrated, irrespective of other criteria like tumour size, SCC of the thin skin of the pinna are classified as T4 category. As therapy considerably depends on the TNM stage a review of the prognostic value of cartilage infiltration as well as other histological criteria seems to be justified. METHODS: Medical records of all patients (n = 36) being operated for SCC of the pinna between August 1988 and January 2004 at our department were retrospectively analysed with regard to a statistical correlation of histological criteria, cervical lymph node metastases and prognosis. RESULTS: In 36 cases a histological re-evaluation could be performed on the original tumour samples (34 male symbol : 2 female symbol; average age was 76 years, with an age interval of 54 - 99 years). 26 SCC cases were smaller than 2 cm, 8 cases between 2 and 5 cm and 2 cases bigger than 5 cm of size. 36 % of SCC cases had infiltration of the auricular cartilage. Statistical analysis did not show a statistical correlation of either cartilage infiltration, tumour size bigger than 2 cm or 1 cm, tumour grading and tumour depth with regard to lymph node metastases. DISCUSSION: According to our results, cartilage infiltration as single criterion of inclusion into a T4 category should be analysed cautiously. The anatomical peculiarity of the pinna where cartilage lies directly beneath very thin skin should be taken into account. A survey of a bigger group of patients e. g. as a multicenter study would be desirable for such a rare malignancy.

A prospective evaluation of the Essen titanium stapes prosthesis.

OBJECTIVES: This is the first clinical trial to evaluate the suitability of a new titanium stapes prosthesis, which we developed jointly with the Kurz Company (Dusslingen). DESIGN: In a prospective clinical study, patients with otosclerosis underwent stapes surgery using our new titanium stapes prosthesis during a period of 14 months. One year after surgery pre- and postoperative audiograms were performed and all patients participated in a structured interview. SETTING: Tertiary otorhinolaryngological university department PARTICIPANTS: Of 49 patients with otosclerosis, entering the study, two patients were excluded, because they were not located any more. MAIN OUTCOME MEASURES AND RESULTS: All patients experienced a hearing improvement of 21 dB on average except one patient. Sixty percentage of patients achieved a reduction of the air-bone gap to less than 10 dB and 31% of patients having their air-bone gap closed to within 20 dB--averaged across 0.5, 1.0, 2.0 and 4 kHz. The hearing level improved significantly in the air and in the bone conduction thresholds. CONCLUSIONS: This paper presents our first '1 year postimplantation' results of our titanium stapes prosthesis. We consider the development of this implant to be beneficial. The results confirm significant improvement in hearing status and tinnitus levels.

[Biomaterial studies in cultures of human stapedial bone-like cells]. / Untersuchung unterschiedlicher Biomaterialien in einer Knochenzellkultur des menschlichen Steigbügels.

BACKGROUND: Cell culture studies may provide information on the behavior of biomaterials in the intended implant environment. Cell cultures from such an environment could be used for the development of middle ear implants. MATERIAL AND METHODS: Secondary bone-like cell cultures derived from human stapes were exposed to different materials [Al(2)O(3) ceramic, glass ceramic (Ceravital), gold and titanium]. Proliferation was studied for up to 40 days. RESULTS: The proliferation of cultured stapes bone-like cells did not differ significantly between the four tested biomaterials. The well known cytotoxic effect of copper, which was used as a control, was evident. CONCLUSIONS: Four biomaterials [Al(2)O(3) ceramic, glass ceramic (Ceravital), gold and titanium] have similar biocompatibility and no toxicity when tested in human stapes cell cultures. This in vitro model may be of considerable value for the further development of middle ear implants, e.g., when coated with bone morphogenetic proteins.

[Squamous cell carcinoma of the external ear. A carcinoma of old age which requires individualized therapy planning]. / Das Plattenepithelkarzinom der Ohrmuschel. Ein Alterskarzinom erfordert eine individualisierte Therapieplanung.

METHODS: Data for all patients with ear malignancies being operated in our department between August 1988 and March 2001 were retrospectively analyzed for tumor localisation, stage, biometric data, anesthesiological risk factors, therapy and recurrence of the disease. RESULTS: Thirty of 79 patients (29 male, one female; average age 77.2 years, range 54-99 years) with cutaneous malignancies of the external ear were diagnosed as SCC ( n=32 SCC). A total of 17 SCC were smaller than 2 cm, 12 were between 2-5 cm, and three were larger than 5 cm. Only two patients had regional nodal disease, none had distant metastases. The anesthesiological risk was estimated according to the recommendations of the American Society of Anesthesiologists (ASA); 16/30 patients were classified as group 3 or 4, having severe general disease with a decrease in vitality or even vital risks. A total of 24 SSC were primarily operated under local anesthesia. Depending on histology, localisation and size of the SCC local excision, partial or total removal of the auricle was performed. In the remaining 8/32 cases, the primary intervention was performed under general anesthesia, mostly in combination with an ipsilateral neck dissection and a superficial parotidectomy. In 8/32 cases, the SCC had to be re-operated after primary R1 resection. Altogether, eight patients received radiotherapy. In 5/32 cases there was a recurrence of the disease. The average follow-up period of the 13 patients who are still alive is 50 months (17-113). One patient died as a result of the metastasized SCC and 16 patients died due to other diseases. DISCUSSION: Considering the high age and the age-associated general diseases of the patients with SCC of the auricle, differentiation between a radical concept of therapy and its risks and possible therapy-related damage is important. Therefore, individual concepts such as partial removal of the pinna without neck dissection and parotidectomy for the N(0) stage are justified if relevant anesthesiological risk factors have to be taken into account.

[Long-term results of laser-tonsillotomy in obstructive tonsillar hyperplasia]. / Langzeitverlauf nach Laser-Tonsillotomie bei symptomatischer Tonsillenhyperplasie.

BACKGROUND: Carbon-dioxide-laser-tonsillotomy is reconsidered as a procedure to relieve patients in early childhood from obstructive symptoms caused by tonsillar hyperplasia such as snoring or sleep apnea without influencing the immunological function. METHODS AND PATIENTS: The protruding part of the tonsils was removed by a CO (2)-laser delivering 10 - 15 W. During 1993 to 2003, 83 children received laser-tonsillotomy, combined with adenoidectomy 51 children were available for follow-up with a standard questionnaire. The parents were surveyed in average 39 months postoperatively. 5 patients required a subsequent tonsillectomy due to a recurrence of tonsillar hyperplasia. Histological investigations were done. 15 children were reevaluated by clinical examination. RESULTS: Most of the patients were relieved from obstructive symptoms. There was no occurrence of postoperative hemorrhage or peritonsillar abscesses. The histological investigations on the specimens from later performed tonsillectomy (n = 5) showed no evidence of scarring opened crypts. The clinical examination did not reveal any signs of chronic infections. CONCLUSION: The tonsillotomy by carbon-dioxide-laser appears as a suitable and safe technique for the treatment of tonsillar hyperplasia without severe throat infection in early childhood.

[Surgical therapy of malignant melanoma of the external ear]. / Zur chirurgischen Therapie des malignen Melanoms der Ohrmuschel.

METHOD: The data from our patients of the last 10 years were evaluated in relation to survival and recurrence. RESULTS: Very different surgical therapy-in some cases due to refusal of the therapy suggested-was performed in eight patients (including wedge shaped excision as well as ablation of the auricle). The mean survival ranged from 40 months up to the present. One patient died due to a local recurrence and regional and systemic metastases. One patient experienced local recurrence but is still well 16 months after he underwent surgical revision. Two patients died independently of the tumor. DISCUSSION: Comparison of our results with those of other studies confirms that the extent of the applied resection has of minor effect on recurrence and survival for this disease. Tumor thickness is the most important independent prognostic factor.

[A bone-destroying tumor of the maxilla. Reparative giant cell granuloma or brown tumor?]. / Knochendestruierender Tumor der Kieferhöhle. Reparatives Riesenzellgranulom oder brauner Tumor?

Brown tumors are focal bone lesions caused by an increased osteoclastic activity and fibroblastic proliferation within a primary or more rarely secondary hyperparathyroidism. They are named after their typical brown hemorrhagic stroma with its also typical giant cell formations. We report the case of a 31-year-old pregnant patient with a rapidly growing tumor of her left maxilla whose first symptoms during pregnancy mimicked chronic sinusitis. After swelling of the cheek, diplopia, and recurrent epistaxis appeared, she was referred to our Department for further diagnostics. After CT scan, biopsy was performed under the presumption of a malignant process with the surprising histological result of a reparative giant cell granuloma. At the same time, hyperthyroidism and nodular goiter were diagnosed and further endocrinological examinations were planned. Not until a parathyroid adenoma was diagnosed after urgent operation of the maxillary process (loose molar teeth and displacement of the left bulbus) could the tumor be interpreted and detected within this context of primary hyperparathyroidism as a brown tumor. The brown tumor should be taken into consideration as a rare differential diagnosis of a bone-destroying process of the facial bones. We discuss the clinical signs, diagnostics, and therapy for this case as well as the relevant literature. The reparative giant cell granuloma represents an important differential diagnosis and cannot be distinguished from a brown tumor by histological examination or radiological findings without complete information about the clinical signs and the endocrinological status of the patient.

[A bone-destroying tumor of the maxilla. Reparative giant cell granuloma or brown tumor?] / Knochendestruierender Tumor der Kieferhöhle : Reparatives Riesenzellgranulom oder brauner Tumor?

Brown tumors are focal bone lesions caused by an increased osteoclastic activity and fibroblastic proliferation within a primary or more rarely secondary hyperparathyroidism. They are named after their typical brown hemorrhagic stroma with its also typical giant cell formations.We report the case of a 31-year-old pregnant patient with a rapidly growing tumor of her left maxilla whose first symptoms during pregnancy mimicked chronic sinusitis.After swelling of the cheek, diplopia, and recurrent epistaxis appeared, she was referred to our Department for further diagnostics.After CT scan, biopsy was performed under the presumption of a malignant process with the surprising histological result of a reparative giant cell granuloma. At the same time, hyperthyroidism and nodular goiter were diagnosed and further endocrinological examinations were planned.Not until a parathyroid adenoma was diagnosed after urgent operation of the maxillary process (loose molar teeth and displacement of the left bulbus) could the tumor be interpreted and detected within this context of primary hyperparathyroidism as a brown tumor.The brown tumor should be taken into consideration as a rare differential diagnosis of a bone-destroying process of the facial bones.We discuss the clinical signs, diagnostics, and therapy for this case as well as the relevant literature. The reparative giant cell granuloma represents an important differential diagnosis and cannot be distinguished from a brown tumor by histological examination or radiological findings without complete information about the clinical signs and the endocrinological status of the patient.

[Reconstruction of the superstructure of the stapes in guinea pigs with biovitro ceramic and silicone foil]. / Rekonstruktion des Steigbügeloberbaus beim Meerschweinchen mit einer Biovitrokeramik und Silikonfolie.

BACKGROUND: The reconstruction of the stapes superstructure is still a problem. Efforts for the fixation of implants on the footplate did not show satisfying results yet. METHODS: In 6 guinea pigs a biovitro ceramic (Bioverit) was placed on the stapes footplate after removal of the superstructure. The exclusive bony fixation of the implants on the footplate should be achieved by the use of silicone foils. For control purposes replantation of autologous ossicles was done in one group of 3 animals and a sham operation was performed without any use of implants in the other group of 6 guinea pigs. RESULTS: After 21 weeks not only bony fixation of the implant with the footplate was observed, but furthermore with the wall of the middle ear. Bone formation was detected along the silicone foils. In the first control group of animals we found bony fixation of the replanted ossicles and even a bow-shaped reconstruction of the stapes superstructure in the second. CONCLUSIONS: The guinea pig was not an ideal model for questions of middle ear reconstructions due to its enormous potential for bone formation. In this animal model bony fixation of glass-ceramic with the stapes-footplate could be induced.

[Unilateral opacification of the paranasal sinuses in CT or MRI: an indication of an uncommon histological finding]. / Die einseitige Verschattung der Nasennebenhöhlen im CT oder MRT--Hinweis für einen seltenen histologischen Befund.

BACKGROUND: Clinical and radiological differentiation between subacute or chronic sinusitis and differential pathologies such as malignoma, inverted papilloma or mycosis can be very difficult. In some cases the CT- or MRI-scan shows a unilateral opacification of the paranasal sinuses. Which histological results can be found in patients with persisting sinusitis related problems and a unilateral opacification of the paranasal sinuses in the CT- or MRI-scan? There are only a few publications on this topic. PATIENTS: In a prospective study between June 1998 and November 1999 all patients who underwent surgery in our Department for subacute or chronic sinusitis problems were included into our study group if they had a unilateral opacification of the paranasal sinuses. Thereafter, the same neuroradiologist verified the unilateral radiological findings on CT or MRI, unaware of the clinical and histological findings. Cases with a pre-existing histological examination, previous operation or injury to the paranasal system were excluded from this study. Data on clinical symptoms, radiological and histological findings were analysed. RESULTS: 43 cases with unilateral opacified paranasal sinuses were diagnosed by means of CT or MRI. These were comprised of 24 males and 19 females with an average age of 43.6 years (range 6 to 88 years). The major findings of our study were as follows: Firstly unilateral opacification of the paranasal sinuses is often (19/43 cases or 43%) associated with diseases othe than simple chronic sinusitis (8 inverted papilloma, 5 malignoma, 3 mycoses and one brown tumor, one osteoidosteoma and one haemangioma). Secondly the incidence of significant pathology other than simple chronic sinusitis rises strikingly with increasing age of the patient. For instance pathologies other than simple chronic sinusitis were found in 14% (1/7) of cases in the under 16 years group, 27% (6/22) of cases in the 16-60 years group and in 86% (10/12) of cases in the over 60 years group. Concerning clinical signs of our patients with unilateral sinus opacity 7 of 11 patients (63%) with epistaxis and 3/5 with diplopia had histological findings other than simple chronic sinusitis. In contrast unilateral rhinorrhea, unilateral nasal congestion and cephalgia were not of predictive value. CONCLUSION: Unilateral opacification of paranasal sinuses in the CT or MRI is--especially at a higher age--an indice for a neoplasm or mycotic sinusitis and therefore an early histological diagnosis or operative treatment is always suggested.

[The ulnar artery or the radial artery can be used alternatively in the free underarm flap]. / Die Arteria ulnaris kann alternativ zur Arteria radialis in den freien Unterarmlappen einbezogen werden.

BACKGROUND: The free, microvascular forearm flap is harvested and transplanted with the radial artery most frequently. Lovie and coworkers published the possibility to elevate this flap with the ulnar artery in 1984. Later on we introduced a DOPPLER-sonographic method to determine the artery which is dominant for the perfusion of the hand in order to leave this artery in the forearm. This procedure might minimize the donor site morbidity. METHOD: In 9 years we treated 30 consecutive patients this way and interviewed them for dysaesthesia in contact with coldness. Furthermore we performed a standardized exposition to 17 degrees C cold water. RESULTS: In 4 of 30 forearm flaps we had to experience flap necrosis. One patient suffered from dysaesthesia during extreme exposure to coldness (motorcycling during the winter without gloves). None of the patients showed dysaesthesia after one minute of cold water exposure. DISCUSSION: Flap necrosis was relatively frequent in our patients but not related to the feeding vessel. On the other hand perfusion related donor site morbidity was extremely rare. To use the radial or the ulnar artery alternatively as the feeding vessel for transplantation of the forearm flap seems to be reasonable and keeps feared complications (disturbance of perfusion, cold-intolerance) rare.

Biocompatibility testing of new polymers in a moving implant bed.

Total reconstruction of the auricle requires a skillful surgical technique and an appropriate material for the shape-supporting frame. Up to now, there is no such material apart from autologous rib cartilage. The combination of chronic microtraumatization of adjacent tissue caused by the mobility of an implant bed such as the auricle and the foreign-body reaction to currently available artificial polymers frequently results in extrusion. In our animal model (rats), polymers of different elasticity were implanted in a moving implant bed to analyse differences in foreign-body reaction related to implant elasticity. The results were significantly better for a rather stiff control material (porous polyethylene). A contributing factor may be better fixation of the implant material by tissue ingrowth into its micropores.

Perforation of the posterior tracheal wall during percutaneous dilatational tracheotomy.

Dilatative percutaneous tracheotomy is more and more indicated in intensive-care medicine. We report on the perforation of the posterior tracheal wall observed in 3 patients after this procedure. In 2 patients the tracheo-oesophageal fistula was closed by the use of a pediculated flap from the infrahyoideal muscle. The third patient died due to the underlying disease. As demonstrated by the 3 cases reported here, this complication cannot be avoided in every case neither by the use of an endoscope nor by extensive personal experience of the physician. The possibility of this complication should be known, because it seems to be typical of this procedure. In the case of perforation of the posterior tracheal wall, active surgical treatment seems to be a successful method to deal with this complication.

[Paraffinoma--a rare complication following endonasal surgery]. / Paraffinome--eine seltene Komplikation nach endonasaler Chirurgie.

BACKGROUND: Paraffin is a mineral oil which was discovered by Reichenbach in 1830. Injection of paraffin into tissue causes a foreign body reaction that results in the formation of a paraffinoma. METHODS: We are reporting on two cases of paranasal paraffinomas, in a 30-year-old male three months after a septorhinoplasty in which paraffin nasal packing was used and in a 56-year-old female patient two months after sinus surgery. RESULTS: A paraffinoma is probably caused by penetration of paraffin through a mucous membrane defect into the adjacent soft tissue. Paraffinomas are usually treated by excision. Although recurrences are frequent, a complete removal should be attempted because of the potential carcinogenicity of paraffin. CONCLUSION: Paraffinomas must be considered in the differential diagnosis of periorbital or paranasal swellings that occur months after endonasal procedures where paraffin packing was used.

[Surgical treatment of acoustically-induced vertigo (Tullio phenomenon)]. / Zur operativen Behandlung des akustisch induzierten Schwindels (Tullio-Phänomen).

BACKGROUND: Tullio phenomenon is defined as noise induced vertigo. Other authors have attributed this symptom to either a perilymphatic fistula or postinflammatory adhesions between the stapes foot plate and the vestibular end organs. METHOD: In this paper two cases are described in which acoustically induced vertigo was explained by abnormal mobility of the stapes. RESULTS: The stapes was stabilized by the placement of cartilage chips beside the crurae of the stapes. Both cases demonstrated long term success, i.e. 4 and 5 years postoperatively.