[Structured oral examination ("guided questions") as a method for objectifying the ENT specialist examination in Germany]. / Strukturierte mündliche Prüfung ("guided questions") als Methode zur Objektivierung der HNO-Facharztprüfung in Deutschland.

On behalf of the federal Ministries of Health, the various German medical associations organize and conduct the board certification examinations for becoming an ENT specialist at the end of residency. The oral examination comprises a collegial discussion that should last at least 30 min and which rarely exceeds 45 to 60 min in practice. The current article describes the quality criteria upon which examinations in general should be based, and lists the most common mistakes during conduction of oral examinations. Using "oral guided questions" (OGQ or GQ) can guarantee a high degree of standardization, objectivity, transparency, and justiciability. The principles of a GQ-guided examination are described and specified by a typical example. Experiences with this form of examination from the federal states of Brandenburg and Thuringia are presented.

["Hybrid tracheostomy": a low risk procedure for tracheostomy in COVID-19 patients]. / "Hybridtracheostomie" ­ ein risikoarmes Verfahren der Tracheostomie bei COVID-19-Patienten.

BACKGROUND: Tracheostomy in ventilated patients suffering from Coronavirus disease 2019 (COVID-19) carries an increased risk of exposure to virus-containing aerosol for the staff. OBJECTIVE: Evaluation of a risk-reduced procedure for tracheostomy. METHOD: Presentation of "hybrid tracheostomy": a method combining the advantages of conventional surgical and percutaneous dilative tracheostomy. RESULTS: Tracheostomy of six patients using the hybrid method without any complications. CONCLUSION: "Hybrid tracheostomy" offers a minimally invasive and safe procedure with low risk of exposure to virus-containing aerosol.

[MEDCARE for People in Eritrea : A report on 9 years' help through self-help]. / MEDCARE for People in Eritrea : Ein Bericht über 9 Jahre Hilfe zur Selbsthilfe.

The current article is an experience report on the establishment of an ENT clinic in Asmara/Eritrea and the organization of regular work stays for the further education of local colleagues. Objectives of the project are content and structural support for self-help and thus achievement of sustainable development aid, which benefits both the medical development of the country and the care of the local patients.

[Tonsil surgery in Brandenburg-trends between 2013 and 2017]. / Operationen an den Gaumenmandeln im Land Brandenburg ­ Entwicklungen von 2013 bis 2017.

BACKGROUND: The frequency of tonsil surgery in Brandenburg (BB) during the period from 2013 to 2017 is analyzed. Causes and possible consequences of the trends are discussed. MATERIALS AND METHODS: An OPS code-based survey is carried out in the 10 ENT hospitals in BB and using the data from the federal states (Federal Statistical Office). In addition, the respective heads of ENT departments are interviewed concerning the indication for tonsillectomy (TE). The average number of operations in 2013/2014 is compared to that in 2017 (BB) and 2016 (federal states). RESULTS: In 9/10 participating hospitals in BB, 10,302 operations were performed, thereof 58.4% as TE, 19.0% as tonsillotomy (TT), 13.7% as abscess tonsillectomy (abscess TE), and 8.9% other. In BB in 2017 in comparison to 2013/2014, because of the decrease in TE by 45.6%, a total of 21.1% less operations were performed, while TT and abscess TE increased by 32% and 18%, respectively. The average age at surgery was 28.1, 38.1, and 5.9 years for TE, abscess TE, and TT, respectively. The entire trend for Germany until 2016 on the basis of 395,674 cases reflects a decrease in TE (30.7%) and abscess TE (14%), while TT was performed 27.5% more often, resulting in a total decrease of 21.3%. The interviewed persons follow the "justifiable operation indications" of the German guideline from 2015 and adapted their previous practice. CONCLUSION: Our survey and results indicate that the massive decrease of TE in BB is associated with the "justifiable operation indications" of the 2015 German guidelines on inflammatory diseases of the tonsils. TE is mainly performed in adults. Therefore, research concerning conservative versus surgical treatment for recurrent tonsillitis is urgently needed for this age profile.

Induction chemotherapy (IC) followed by radiotherapy (RT) versus cetuximab plus IC and RT in advanced laryngeal/hypopharyngeal cancer resectable only by total laryngectomy-final results of the larynx organ preservation trial DeLOS-II.

Background: The German multicenter randomized phase II larynx organ preservation (LOP) trial DeLOS-II was carried out to prove the hypothesis that cetuximab (E) added to induction chemotherapy (IC) and radiotherapy improves laryngectomy-free survival (LFS; survival with preserved larynx) in locally advanced laryngeal/hypopharyngeal cancer (LHSCC). Patients and methods: Treatment-naïve patients with stage III/IV LHSCC amenable to total laryngectomy (TL) were randomized to three cycles IC with TPF [docetaxel (T) and cisplatin (P) 75 mg/m2/day 1, 5-FU (F) 750 mg/m2/day days 1-5] followed by radiotherapy (69.6 Gy) without (A) or with (B) standard dose cetuximab for 16 weeks throughout IC and radiotherapy (TPFE). Response to first IC-cycle (IC-1) with ≥30% endoscopically estimated tumor surface shrinkage (ETSS) was used to define early responders; early salvage TL was recommended to non-responders. The primary objective was 24 months LFS above 35% in arm B. Results: Of 180 patients randomized (July 2007 to September 2012), 173 fulfilled eligibility criteria (A/B: larynx 44/42, hypopharynx 41/46). Because of 4 therapy-related deaths among the first 64 randomized patients, 5-FU was omitted from IC in the subsequent 112 patients reducing further fatal toxicities. Thus, IC was TPF in 61 patients and TP in 112 patients, respectively. The primary objective (24 months LFS above 35%) was equally met by arms A (40/85, 47.1%) as well as B (41/88, 46.6%). One hundred and twenty-three early responders completed IC+RT; their overall response rates (TPF/TP) were 94.7%/87.2% in A versus 80%/86.0% in B. The 24 months overall survival (OS) rates were 68.2% and 69.3%. Conclusions: Despite being accompanied by an elevated frequency in adverse events, the IC with TPF/TP plus cetuximab was feasible but showed no superiority to IC with TPF/TP regarding LFS and OS at 24 months. Both early response and 24 months LFS compare very well to previous LOP trials and recommend effective treatment selection and stratification by ETSS. Clinical trial information: NCT00508664.

A two-arm multicenter phase II trial of one cycle chemoselection split-dose docetaxel, cisplatin and 5-fluorouracil (TPF) induction chemotherapy before two cycles of split TPF followed by curative surgery combined with postoperative radiotherapy in patients with locally advanced oral and oropharyngeal squamous cell cancer (TISOC-1).

BACKGROUND: Induction chemotherapy (ICT) with docetaxel, cisplatin and fluorouracil (TPF) followed by radiotherapy is an effective treatment option for locally advanced head and neck cancer. This phase II study investigated the effectivity of a split-dose TPF ICT before surgery for locally advanced resectable (stage III/IVA) oral and oropharyngeal cancer. PATIENTS AND METHODS: Patients received TPF split on two dosages on days 1 and 8 per cycle (30 mg/m2 docetaxel, 40 mg/m2 cisplatin, 2000 mg/m2 fluorouracil per week). Responders (reduction tumor volume ≥30% after first cycle) received three 3-week cycles and non-responders only one cycle before surgery and postoperative radio(chemo)therapy (RCT). The primary endpoint was progression-free survival rate after 24 months. Secondary endpoints were amongst others overall survival, histopathological response to ICT, toxicity, quality of life and swallowing function. RESULTS: Fifty-four patients (91% stage IVA, 87% male, 72% oropharyngeal cancer, 70% responders) were eligible for a per-protocol analysis. The progression-free survival rate after 24 months was 88.5% for responders and 60.6% for non-responders (P = 0.005). The overall survival rate after 24 months was 97.3% for responders and 73.7% for non-responders (P = 0.032). The rate of histopathological complete remission of the primary tumor was higher in responders (P = 0.015). High-risk classification for postoperative RCT was lower in responders (P < 0.0001). The most common grade 3+ adverse event was neutropenia in 26% of patients during ICT and mucositis in 13% during postoperative RCT. During treatment and follow-up quality of life and swallowing function was not different between responders and non-responders. CONCLUSION: Patients with oral and oropharyngeal cancer responding to split-dose TPF before surgery and postoperative RCT show good oncological results. The tri-modal treatment regime was well tolerated. ICT using tumor response as criterion for duration of ICT before surgery of oral and oropharyngeal cancer merits additional investigation in a phase III study. CLINICAL TRIAL NUMBER: NCT01108042.

[Obstructive sleep apnea syndrome in the setting of Gorlin-Goltz syndrome]. / Obstruktives Schlafapnoe-Syndrom bei Gorlin-Goltz-Syndrom.

Goltz-Gorlin syndrome is a rare autosomal dominant hereditary disease associated with a high rate of spontaneous mutation. Diagnosis is based on clinically defined major and minor criteria. The disease is caused by a gene mutation locating to chromosome 9q22-31. We report on a young Goltz-Gorlin syndrome patient with obstructive sleep apnea syndrome. Due to intolerance to continuous positive airway pressure (CPAP) therapy and in order to avoid a tracheotomy, we opted for an alternative therapy comprising interdisciplinary multi-level surgery.

[Atlantoaxial malformation as a rare cause of dysphagia and snoring]. / Eine atlantoaxiale Fehlbildung als seltene Ursache für Dysphagie und Rhonchopathie.

Abnormalities of the atlantoaxial spine are very rare variants. Bony outgrowths, osteophytes, clefts and aplasia may be misinterpreted as degenerative diseases. One patient presented with intermittent dysphagia and snoring and CT and MRI scans of the cervical spine showed an accessory bone located anterior to the atlas and axis. Atlantoaxial anomalies are often incidental findings without clinical symptoms. Such changes are rarely the cause of intermittent dysphagia and snoring.

[Palliative surgery in squamous cell carcinoma of the anterior floor of the mouth]. / Palliative Chirurgie bei Plattenepithelkarzinom des vorderen Mundbodens.

A 62 year old patient presented with a bleeding, incurable squamous cell carcinoma of the anterior floor of the mouth. A curative concept was not possible. After four palliative surgical procedures, a definitive and a palliative radiation therapy and a palliative chemotherapy, the patient remained free of tumor in the head and neck region for 2 years after the initial treatment. Using a combination of palliative procedures, it is possible not only to achieve a full local remission but also to provide a high quality of life.

18F-FDG PET for detecting recurrent head and neck cancer, local lymph node involvement and distant metastases. Comparison of qualitative visual and semiquantitative analysis.

AIM: Assessment of the clinical value of (18)F-FDG-PET for detection of recurrent head and neck cancer, local lymph node involvement and distant metastases comparing a qualitative visual with a semiquantitative analysis (SUV values). PATIENTS, METHODS: Retrospective evaluation of 73 (18)F-FDG PET studies in 55 patients by use of a four-step qualitative visual grading system and calculation of standard uptake values in pathological lesions. Calculation of SUV values in normal regions for generating a map of physiological (18)F-FDG distribution. Correlation to histopathological findings and clinical follow-up. RESULTS: 1. Qualitative visual analysis of (18)F-FDG PET studies: a) local recurrence sensitivity 79%, specificity 97%, positive predictive value 95%, negative predictive value 85%, and diagnostic accuracy 89%; b) local metastatic lymph nodes 100%, 95%, 85%, 100%, 96%; c) distant metastases 100%, 98%, 86%, 100%, 98%, respectively. 2. Semiquantitative analysis had only little incremental, non-significant value in comparison to qualitative visual analysis for the detection of a local recurrence in two patients: a) local recurrence: sensitivity 83%, specificity 100%, positive predictive value 100%, negative predictive value 88%, and diagnostic accuracy 93%; b) local metastatic lymph nodes or c) distant metastases did not change in comparison to qualitative visual analysis. CONCLUSION: (18)F-FDG PET is an effective tool for re-staging of patients with suspected recurrence after therapy for head and neck cancer.

[Diagnosis with (18)F-FDG PET scan after larynx preservation by primary radiochemotherapy]. / Diagnostik mittels (18)F-FDG-PET nach Larynxorganerhalt durch primäre Radiochemotherapie.

PATIENTS AND METHODS: In a group of 20 patients undergoing chemoradiation for larynx organ preservation after diagnosis of laryngeal and hypopharyngeal carcinoma, (18)F-fluordeoxyglucose positron emission tomography ((18)F-FDG-PET) was performed before the start of therapy. After i.v. application of 240 MBq FDG, a dynamic PET in 3-D-mode was performed over 90 min (Siemens CTI ECAT EXACT HR(+)). Analysis was done visually and semiquantitatively (60-90 min p.i.) following iterative reconstruction. Additional (18)F-FDG-PET investigations were done and correlated with the clinical outcome in 16/20 patients at 3 months and in 14/20 patients at 6 months after the end of therapy. RESULTS: In 17/20 patients (85%), the preclinical (18)F-FDG-PET correlated well with the histologically confirmed primary tumor. Three cases were false negatives. In one case this was due to an increased glucose value (203 mg%). After 3 months, 8/13 (62%) patients showed a positive correlation between clinical and PET results (sensitivity 100%, specificity 70%). After 6 months, 9/11 (82%) patients presented clinically normal PET results. PET results were false negative in one case (sensitivity 67%, specificity 88%). CONCLUSION: The data of our trial slightly reduce the enthusiasm of early (18)F-FDG-PET detection of residual disease after chemoradiation in resectable laryngeal or hypopharyngeal cancer. Further trials should optimize the calculation integrating the exact quantification of glucose metabolism with the aim of improving sensitivity and specificity.

[Cricohyoidopexy (CHP) and Cricohyoidoepiglottopexy (CHEP). Indication, complications, functional und oncological results]. / Krikohyoidopexie (CHP) und Krikohyoidoepiglottopexie (CHEP). Indikationen, Komplikationen, funktionelle und onkologische Ergebnisse.

BACKGROUND: Subtotal laryngectomy with Cricohyoido(epiglotto)pexy (CHEP and CHP) is a commonly used surgical procedure in France, Italy and North America, but it is rarely carried out in Germany,where most laryngeal carcinomas staged T1-T3 are resected endoscopically or with total laryngectomy. OBJECTIVE: To identify indications for the CHEP and CHP in a setting that uses endolaryngeal procedures as a standard approach to organ preserving surgery in laryngeal cancer patients. PATIENTS: Nineteen patients with primary (n=15) or recurrent (n=4), supra- or transglottic carcinoma or carcinoma of the anterior commissure staged (r)T1b-4N0-2cM0 were treated with subtotal laryngectomy with CHEP (with or without neck dissection/radiotherapy) between October 1997 and June 1999. RESULTS: Undisturbed deglutition without aspiration and respiration without tracheotomy was achieved in 17/19 patients. Three patients showed temporary pneumonia from aspiration and two patients needed further treatment for endolaryngeal synechia. Three patients died of unrelated causes. Four patients were diagnosed with local recurrence: Two of them died from tumor, two patients had curative total laryngectomy as salvage surgery. Fourteen patients are living free of disease 24-40 months after therapy. CONCLUSION: CHEP is a subtotal laryngectomy with increased postoperative morbidity, but good functional results. Assuming a scrupulous indication for the extended tumors the oncological results of the CHEP are satisfying, too.

Chirurgische Zugangswege zum Mesopharynx.

Because of their localization and their extent, tumours of the deep oral cavity, the oropharynx and the parapharyngeal space are rarely accessible for CO2 laser dissection. Especially malignant tumours of the base of the tongue and the vallecula as well as salivary gland-related tumours of the parapharyngeal space need wide conventional surgical exposure to allow: resection respecting tumor margins (R0); oropharyngeal and tongue reconstruction using local and microvascular grafts; prevention of mass-bleeding caused by infectious destruction of large blood vessels. This article reviews the different surgical approaches to oropharyngeal tumours with special reference to "mandibular swing" procedures. Moreover, different graft techniques are critically assessed.