[Use of flexible transnasal esophagogastroscopy in patients with unclear globus sensation]. / Einsatz der flexiblen transnasalen Ösophagogastroskopie bei Patienten mit unklarem Globus pharyngeus.

BACKGROUND: Globus pharyngeus is a common symptom with considerable suffering. Globus sensation can be caused by reflux. In many places, endoscopy of the esophagus is recommended for clarification, especially when there is a question about the presence of a hiatal hernia as the cause of reflux. Transnasal esophagogastroscopy (TNE) represents an alternative to conventional gastroesophagoscopy. It enables a quick low-complication examination of the upper aerodigestive tract in the sitting, non-sedated patient. OBJECTIVE: The aim of this work was to assess the feasibility of outpatient TNE in patients with globus sensation. Furthermore, the results of dual-probe pH monitoring were compared with the results of TNE in order to assess the value of TNE in the clarification of globus sensation and reflux. MATERIALS AND METHODS: In 30 patients with globus symptoms, 24-hour dual-probe pH monitoring and TNE were performed. In pH monitoring, reflux number, fraction time, reflux surface area index, and DeMeester score were evaluated as indicators of laryngopharyngeal reflux (LPR) and gastroesophageal reflux (GERD). Abnormalities of the esophageal mucosa and the gastroesophageal junction were recorded in TNE. The results were compared. RESULTS: The TNE could be performed without any complications. Mean examination time was 5.34 ± 0.12 min. Reflux was measured in 80% of the patients (24/30) with pH monitoring. In almost half of these patients (46%), abnormalities were detected in TNE as indirect evidence of reflux. In addition to an axial hiatal hernia, these included mucosal changes such as erosive esophagitis and Barrett's metaplasia. Patients with a hiatal hernia also suffered significantly more often from LPR than patients without a hernia (9:1). CONCLUSION: TNE is a quick and safe examination method for diagnosing patients with an unclear globus sensation. Detection of a hiatal hernia can be seen as an indication of reflux disease. Lack of evidence of a hernia does not rule out reflux. Thus, TNE is a useful addition to pH monitoring in patients with globus sensation, because reflux-related changes in the mucosa can be recognized early and adequately treated.

Inpatient treatment of patients with acute idiopathic peripheral facial palsy: A population-based healthcare research study.

OBJECTIVES: To determine the inpatient management for patients with acute idiopathic facial palsy (IFP) in Thuringia, Germany. DESIGN: Population-based study. SETTING: All inpatients with IFP in all hospitals with departments of otolaryngology and neurology in 2012, in the German federal state, Thuringia. MAIN OUTCOME MEASURES: Patients' characteristics and treatment were compared between departments, and the probability of recovery was tested. RESULTS: A total of 291 patients were mainly treated in departments of otolaryngology (55%) and neurology (36%). Corticosteroid treatment was the predominant therapy (84.5%). The probability to receive a facial nerve grading (odds ratio [OR=12.939; 95% confidence interval [CI]=3.599 to 46.516), gustatory testing (OR=6.878; CI=1.064 to 44.474) and audiometry (OR=32.505; CI=1.485 to 711.257) was significantly higher in otolaryngology departments, but lower for cranial CT (OR=0.192; CI=0.061 to 0.602), cerebrospinal fluid examination (OR=0.024; CI=0.006 to 0.102). A total of 131 patients (45%) showed a recovery to House-Brackmann grade≤II. A pathological stapedial reflex test (Hazard ratio [HR]=0.416; CI=0.180 to 0.959) was the only independent diagnostic predictor of worse outcome. Prednisolone dose >500 mg (HR=0.579; CI 0.400 to 0.838) and no adjuvant physiotherapy (HR=0.568; CI=0.407 to 0.794) were treatment-related predictors of worse outcome. CONCLUSIONS: Inpatient treatment of IFP seems to be highly variable in daily practice, partly depending on the treating discipline and despite the availability of evidence-based guidelines. The population-based recovery rate was worse than reported in clinical trials.

Population-based analysis of tonsil surgery and postoperative hemorrhage.

Although tonsil surgery is one of the most frequent otorhinolaryngological procedures, not many population-based regional or country-wide studies are published on the incidence of postoperative bleeding and its risk factors. 2,216 patients underwent tonsil surgery in 2012 in Thuringia, a federal state in Germany. Most frequent indications were recurrent tonsillitis (44 % of all cases), tonsillar abscess (27 %), and tonsillar hyperplasia (20 %). 29 % of the patients were <10 years of age. Most frequent methods of surgery were tonsillectomy (73 %) and tonsillotomy (19 %). 215 patients (10 %) had 221 events of a postoperative hemorrhage. Re-surgery for hemostasis was necessary in 137 patients (6 %). The interval to re-surgery was 4.4 ± 4.6 days. The re-surgery rate was 8, 0.2, and 15 % after tonsillectomy, tonsillotomy, and radical tonsillectomy, respectively. In cases of recurrent tonsillitis, male gender (p < 0.001), age >24.78 years (median; (p = 0.018), and waiving of perioperative antibiotics (p = 0.029) were independent factors associated with hemorrhage. In cases of tonsillar hyperplasia tonsillectomy instead of tonsillotomy, the only significant risk factor was postoperative hemorrhage (p = 0.005). The overall incidence of tonsillar surgery was 87.6/100,000. The highest incidence was seen for patients 3-4 years of age with 862.7/100,000. In children <10 years, the incidence was always higher for boys than for girls. Throughout all age groups, a reverse gender relation was only seen, if surgery was indicated for recurrent tonsillitis. We recommend establishing national guidelines for indication of tonsil surgery, especially of tonsillectomy, including recommendations for perioperative care to decrease variations in tonsil surgery rates and minimize postoperative complications.

Chronic vocal cord palsy in Thuringia, Germany: a population-based study on epidemiology and outcome.

Although surgical treatment of patients with chronic vocal cord palsy (VCP) is an integral part of clinical routine of otorhinolaryngologists, there is nearly no population-based data published on incidence and efficiency of this surgery country-wide or nation-wide. 1430 patients with chronic VCP were treated in a department of otorhinolaryngology between 2005 and 2010 in Thuringia, Germany. VCP was unilateral and bilateral in 63 and 18%, respectively. The affected side was not documented in 20%. Iatrogenic lesions of the recurrent nerve (42%) and neoplastic infiltration (27%) were the leading etiologies. 192 patients (13%) received surgical treatment. 31% of patient needed more than one surgery. The rate of surgeries was higher for bilateral VCP (p < 0.0001). Vocal cord augmentation was the most frequent surgery for unilateral VCP and posterior cordectomy for bilateral VCP. The complication rate was high (16%), but not different between unilateral and bilateral VCP (p = 0.108). The risk for tracheostomy was higher in the bilateral VCP group (p < 0.0001). Voice improvement was better after treatment of unilateral VCP (p < 0.0001). Breathing improvement was more frequent after bilateral VCP (p = 0.028). Dysphagia did not improve significantly. The rate of better voice, breathing, and swallowing function was higher in patients treated surgically than without surgery (all p < 0.0001). The rate of patients admitted for treatment of vocal fold palsy was 9.9/100,000 habitants. The surgical rate of VCP was 1.38/100,000 habitants. This population-based analysis shows that surgery for VCP is performed with higher incidence than expected effectively, but with relevant risks in daily routine of otorhinolaryngologists.

Parotidectomy and submandibulectomy for benign diseases in Thuringia, Germany: a population-based study on epidemiology and outcome.

Although salivary gland surgery for benign diseases is an integral part of clinical routine of head and neck surgeons, there is not many population-based data published on incidence and efficiency of this surgery. Parotidectomy was performed in 180 patients and submandibulectomy in 97 patients for benign diseases in eight otorhinolaryngology and two maxillofacial surgery departments in Thuringia, Germany, in 2005. All patients were analysed regarding patients' characteristics, therapy, complications and further course of disease. Predominant indications were epithelial tumours for parotidectomy (79 %) and sialolithiasis for submandibulectomy (50 %). The most frequent tumour types were pleomorphic adenoma (46 %) and Warthin tumours (29 %). Pleomorphic adenoma was significantly more frequent in female patients and Warthin tumours in male patients and smokers. The incidence of parotidectomy, i.e. the surgical rate, was 7.8/100,000 habitants and of submandibulectomy 4.1/100,000 habitants. One hundred and seventy-eight tumours including 154 epithelial tumours resulted in an incidence of 7.6/100,000 habitants for all treated tumours and of 6.6/100,000 for epithelial tumours, respectively. The majority of parotid cases were treated by lateral parotidectomy (79 %). Relevant complications were observed in 22 % of patients. After parotidectomy and submandibulectomy a postoperative facial palsy was observed in 28 and 2 % of cases, respectively. Only 1 % was permanent. During a mean follow-up time of 9.6 months, 3 % of parotidectomy patients developed a Frey's syndrome needing treatment and 0.8 % developed a tumour recurrence. This population-based analysis shows that salivary gland surgery is performed in higher incidence than expected, effectively and with low-risk in daily routine of head and neck surgeons.

[Health services research on paranasal sinus surgery in Thuringia: epidemiologic key data and outcome]. / Versorgungsforschung zu Nasennebenhöhlenoperationen in Thüringen: Epidemiologie und Ergebnisse.

BACKGROUND: Although modern minimal-invasive paranasal sinus surgery is an integral part of clinical routine of otorhinolaryngologic surgeons, there are no population-based data on incidence and efficiency of this surgery published. MATERIAL AND METHODS: 1,582 patients underwent paranasal sinus surgery in the 8 Thuringian departments of otorhinolaryngology in 2005. All patients were analysed regarding patients' characteristics, therapy, complications and further course of disease. RESULTS: The incidence of paranasal sinus surgery was 46/100,000 for women and higher for men with 72/100,000. Median age was 48 years. Chronic sinusitis was the main reason for surgery (94%; including 33% with nasal polyps) and was performed dominantly as endoscopic sinus surgery (96%). Surgery was performed bilaterally in 75% of the cases and as primary surgery. In most cases at least 2 paranasal sinuses per side were approached. Relevant complications were observed in 4% of patients. During the follow-up time of 45-51 months a recurrence was observed in 9% of cases. Using a multivariate regression analysis, revision surgery, allergic subject and diagnosis of a malignant tumor were significant independent risk factors to predict a recurrence. Older age and longer time of surgery were significant independent risk factors for a complication. CONCLUSION: This population based analysis is showing that modern paranasal sinus surgery is performed in high incidence, effectively and with low-risk on a large scale in daily routine of rhinologic surgeons.

[The possibilities of reflux disease diagnosis by the ear, nose and throat specialist]. / Möglichkeiten der Refluxdiagnostik durch den Hals-Nasen-Ohren-Arzt.

Reflux disease has gained in importance over the last decade since we know that many of the symptoms and diseases of the upper aerodigestive tract might be associated with reflux. However, a distinction needs to be made between extraesophageal reflux (EER) and gastroesophageal reflux disease (GERD). There are several techniques available for the diagnosis of EER. Furthermore, there are various pH monitoring devices to determine acid contamination of the larynx and the pharynx. In addition, flexible transnasal esophagoscopy is a practicable technique for the rapid examination of reflux, its cause as well as the diagnosis of reflux-induced mucosal changes in the esophagus. The present article describes the instruments used for the diagnosis of reflux against the background of our own experience and the international literature.

[Sonographic differential diagnosis of cervical masses]. / Sonographische Differenzialdiagnose von Raumforderungen der Halsweichteile.

One of the main indications for the use of ultrasound by the head and neck specialist is the diagnosis of cervical masses. The examination can be easily performed since all structures of interest are located superficially and are not covered by boney or air-filled structures. Further advantages of ultrasound in contrast to other imaging techniques such as MRI or CT include its high resolution and lack of side effects. Even structures of <5 mm in diameter can be interpreted well. Since ultrasound is fast, has no side effects and can be performed as often as necessary, it represents an excellent diagnostic instrument in the follow-up of patients with head and neck cancer. In addition to the conventional B-scan technique, colour duplex sonography is also often performed today to obtain additional information on the nature of cervical masses. Thus, different entities of cervical lymph nodes can be well differentiated by their pattern of vascularization.

[No correlation between reflux of gastric contents and obstructive sleep apnea]. / Besteht ein Zusammenhang zwischen der Refluxerkrankung und dem obstruktiven Schlafapnoesyndrom?

Reflux of gastric contents can be associated with many ENT disorders. Some authors describe an association with obstructive sleep apnea, but it is not clear whether the reflux causes the apnea or vice versa. Furthermore, authors did not distinguish between gastroesophageal reflux and extraesophageal reflux, which is essential to understand a connection with obstructive sleep apnea. Therefore, we performed polysomnography and two-channel pH testing simultaneously in patients with obstructive sleep apnea syndrome (OSAS) and compared the findings with data of healthy volunteers. After exclusion of a changed sleep architecture due to the pH testing system, the results show that patients with OSAS do not suffer more often from reflux than healthy volunteers. This is true for gastroesophageal as well as for extraesophageal reflux. Furthermore, an increasing number of reflux events during the night is not correlated with the number of apnea events. Thus, in summary our data cannot support the postulation that there is a connection between obstructive sleep apnea syndrome and reflux disease.

[Determination of normal values of extraesophageal reflux in 24-h two-channel pH testing]. / Normalwertbestimmung des extraösophagealen Reflux (EER) in der 24-h-2-Kanal-pH-Metrie.

Extraesophageal reflux (EER) causes multiple diseases of the upper aerodigestive tract. EER is diagnosed by two-channel pH testing. However, little data exist about normal values. Therefore, we performed ambulatory two-channel pH testing in healthy volunteers and determined normal values for the number of reflux episodes, fraction, and reflux area index. These values were determined for pH 14.72 were excluded from the evaluation. In the other patients, the mean number of reflux episodes was 2.6+/-0.9 (95(th) percentile 4.4), the fraction of pH

[Extraesophageal reflux in patients suffering from Zenker's diverticulum]. / Extraösophagealer Reflux und Zenker-Divertikel.

INTRODUCTION: Patients with Zenker's diverticulum often present with a hiatal hernia. Theoretically, the gastric acid fluid could rise up to the hypopharynx producing an injury to the mucosa of Killian's triangle and hypertrophy of the cricopharyngeal muscle. We performed dual-channel pH monitoring in healthy people as a control group and in patients with a Zenker's diverticulum to elucidate the relationship between Zenker's diverticulum and gastroesophageal reflux disease (GERD) as well as extraesophageal reflux (EER). METHODS: Patients with Zenker's diverticulum underwent dual-channel 24-h pH monitoring to exclude the possibility of an EER or a GERD. The measurements were performed in 4 patients preoperatively and postoperatively as well as in 14 patients only postoperatively. The control group consisted of healthy volunteers who did not suffer from a reflux disease (n=20). In each group we determined the number of refluxes, the fraction time, the RAI (reflux area index), and the DeMeester Score Index. In addition we classified the severity of the EER with a grading system which was developed in an earlier study in our department. RESULTS: Patients with a Zenker's diverticulum suffered significantly from EER (p<0.01). The difference between the patients measured preoperatively and the patients postoperatively was minor. More than 72% of the patients suffered from a severe EER. CONCLUSIONS: Patients with a Zenker's diverticulum have a high possibility of suffering from EER and GERD. The pathophysiology of this relationship can only be speculated. In addition to a cricopharyngeal myotomy, long-term therapy with a PPI (proton pump inhibitor) seems indicated.

[Staging of esophageal cancer using ultrasound]. / Staging des Osophaguskarzinoms mittels Ultraschall.

The early diagnosis of esophageal cancer is crucial for the prognosis of the disease. In contrast to cancer of the upper aerodigestive tract, the mucosa of the esophagus is not visible without the appropriate equipment. In addition to endoscopy, imaging of the esophagus is crucial for early detection of the esophageal cancer. Ultrasound of the esophagus can be performed easily and--in contrast to other imaging techniques--without side effects. Different modes of ultrasound can be performed. First, transcutaneous ultrasound allows one to detect tumors of the upper esophagus and its passage into the hypopharynx. Second, endosonography allows one to detect pathologies of the other esophageal regions including the passage into the stomach. The present review discusses the impact of both techniques against the background of the international literature.