Clinical and morphological aspects of adenocarcinomas of the intestinal type in the inner nose: a retrospective multicenter analysis.

Clinical and histological parameters from 117 patients with wood dust-related sinonasal adenocarcinomas of intestinal type (ITAC) were analyzed and correlated with a follow-up period of 5 years at least. The rate of survival for 5 years was 53.1 % and for 10 years 30.2 %. Only 33 patients were free of disease. 74.2 % of patients with recurrences died in relation to ITAC. As expected, tumors of T4-category had the worst prognosis. The mucus content of a tumor was the most important histological parameter. Endonasal methods of surgery had no more positive survival rates after 5 years. An effect of radiotherapy has to be in discussion. The high incidence of tumor recurrences requires control examinations consistently.

Metastatic behaviour of sinonasal adenocarcinomas of the intestinal type (ITAC).

The relative frequency of regional lymphogenic versus distant hematogenic metastases was evaluated in 369 patients with sinonasal adenocarcinoma of the intestinal type (ITAC). We assessed the results of neck dissections for a limited number of patients undergoing this surgical intervention. 117 ITAC patients were followed up for at least 5 years. Neck dissections were performed in 18 cases (15 primary and 3 secondary operations), 4 of which revealed carcinoma-positive lymph nodes. Metastases in lymph nodes were also diagnosed clinically in three other patients adding up to a total of seven individuals (6 % of 117) with lymphogenic metastases. In comparison, distant hematogenic metastases were identified in 15.4 % of these 117 patients. In the second group of 252 patients, the occurrence of distant hematogenic metastases and colorectal adenocarcinomas was registered but no formal follow-up procedure was applied. 50 neck dissections were performed in this group, 46 of which exhibited no histological evidence for metastases in lymph nodes, while in 1 case they were carcinoma-positive. Three additional cases showed clinical signs of metastases in regional lymph nodes. Taken together, our observations indicate that regional lymphogenic metastases are rather rare (about 2 %) in patients with sinonasal adenocarcinoma of the intestinal type. Therefore, the surgery of neck dissection appears not advised as routine intervention in these cases. ITAC patients show a normal prevalence of colorectal adenocarcinomas.

[Preoperative coagulation screening prior to adenoidectomy and tonsillectomy]. / Präoperatives Screening auf Gerinnungsstörungen vor Adenotomie und Tonsillektomie.

BACKGROUND: Laboratory tests are widely used to screen children with planned surgery to detect unknown coagulation defects. This study investigates the predictive value of commonly used coagulation tests (thromboplastin time, partial thromboplastin time and thrombocyte count) compared with a standardized bleeding history. PATIENTS: In 702 patients 500 adenoidectomies and 500 tonsillectomies were done, results of laboratory evaluation and individual bleeding history were evaluated. RESULTS: 9.4 % of all laboratory tests showed abnormal results. 30.5 % of the children awaiting adenoidectomy had a suspicious bleeding history as had 22 % of patients undergoing tonsillectomy. In the clinical course of adenoidectomy no bleeding occurred. After tonsillectomy 15 children (3 %) showed moderate, 12 patients (2.4 %) severe postoperative bleeding. The positive predictive value of coagulation screening reached 6.8 % whereas history alone predicted 9.2 % of observed post tonsillectomy bleeding. CONCLUSIONS: The results of this study demonstrate the lacking effect of laboratory tests to predict postoperative bleeding complications. Taking a careful history of bleeding risks and testing only patients with suspicious history reduces the risk of bleeding more effective. Counseling about bleeding symptoms and postoperative survey of patients are additional measures which may protect the children.

[Nasal sinus carcinoma after wood dust exposure. Morphological spectrum of 100 cases]. / Sinunasale Karzinome nach Holzstaubbelastung. Morphologisches Spektrum an 160 Fällen.

Sinonasal carcinomas are usually of the squamous cell or transitional cell type. Adenocarcinomas of the inner nose and the paranasal sinus correlate with exposure to wood dust. However, this is only true for adenocarcinomas of the intestinal type and not for salivary gland carcinomas or polymorphous low-grade adenocarcinomas. Of 160 cases with a history of wood dust exposure and malignant tumors of the inner nose, 134 were sinonasal adenocarcinomas of the intestinal type (SNAIT). In addition, there were 24 other carcinomas as well as 1 malignant melanoma and 1 malignant synovial tumor. The SNAIT showed various subtypes with great morphological similarities to colorectal adenocarcinomas (papillary tubular cylinder cell: 72.4%; alveolar goblet cell: 5.2%; signet ring cell: 3.7%; transitional type: 18.7%). Highly differentiated adenocarcinomas (G1) and mucinous adenocarcinomas were relatively frequent: they accounted for 23.1% and 29.1% of the 134 SNAIT, respectively. Apart from wood dust, wood additives are discussed as a carcinogenic factor. With the development of SNAIT, a metaplasia-dysplasia-carcinoma in situ sequence is probable. If the clinical course shows few symptoms, the first manifestation of such a tumor often occurs in an advanced stage.

[Papillary tumor of the inner ear: adenoma or carcinoma?]. / Papillärer Tumor des Innenohrs: Adenom oder Karzinom?

A 46-year-old female patient presented relapsed left-sided hearing loss and progressive left facial nerve palsy. At first, the computed tomography (CT) scan and magnetic resonance (MR) imaging did not indicate a diagnosis of a tumorous lesion. Nine years after the first symptoms, a destructive cystic neoplasm of the pars petrosa of the temporal bone was then evident. The lesion was surgically removed by radical resection. Histologically, a papillary tumor of the endolymphatic sac was diagnosed. These tumors tend to become destructive and more or less aggressive, but they do not metastasize. Therefore, the best term for them should be "aggressive papillary tumors of the endolymphatic sac" to avoid classification as an adenoma or adenocarcinoma.

Carcinogenicity assays of wood dust and wood additives in rats exposed by long-term inhalation.

OBJECTIVE: This study evaluates whether wood dust and/or wood preservatives develop a carcinogenic potential against the tissues of the airways of rats. METHODS: The formation of tumors of the respiratory tract after exposure to wood dust was studied in six groups of approximately 60 female Fischer 344 rats exposed by long-term inhalation to mean concentrations of (1) 18 mg/m3 of untreated oak wood dust, (2) wood preservatives containing ca. 1 microgram/m3 lindane and 0.2 microgram/m3 of pentachlorophenol (PCP) in the exposure air, or lindane and 18 micrograms/m3 of PCP (group lindane/PCP vapors, and group oak wood treated with lindane/PCP), (3) 21 or 39 micrograms/m3 of sodium dichromate (calculated as CrO3, group chromate aerosol and group oak wood with chromate), and 72 micrograms/m3 of N-nitrosodimethylamine vapors as positive control. The negative control group consisted of 115 animals (sham-exposed). RESULTS: Tumors of the nasal cavity developed in two rats exposed to chromate aerosol or in combination with wood dust (2/102, 2%). Malignant tumors of the lower respiratory tract were induced only in exposed groups of rats (three adenocarcinomas of the lung and four bronchiolar lung carcinomas, 7/254, 2.8%). More respiratory tract tumors were observed in rats exposed to chromate or wood with chromate (5/102, 5%), also in groups exposed to oak wood dust (oak untreated, oak + chromate, oak + lindane/PCP; together 5/155, 3.2%). Analysis of 'unpreserved' oak wood dust revealed up to 5 micrograms/m3 of chromate. When this exposure was taken into account, eight of nine animals with respiratory tract tumors (including nasal cavity) had exposure to chromate, while only one tumor occurred in the group lindane/PCP. Otherwise the incidence of systemic tumors was increased in animals exposed to lindane/PCP, due in particular to a significantly increased incidence of liver tumors (OR = 3.7; 1.24-11.3; P = 0.019). Fatal (mucoepidermoid) tumors were induced by N-nitrosodimethylamine (NDMA) in the positive control (14/46, 30%). No such tumors of the respiratory tract were observed in the negative control. CONCLUSIONS: Tumors in the respiratory tract were found only in exposed animals, predominantly in the groups which inhaled oak wood dust and chromate stain. Chromate may play a decisive role for the etiology of tumors of the nasal cavity in wood workers. This assumption should be supported by further dose-response studies.

Irradiation of histiocytosis X confined to the oral mucosa.

BACKGROUND: Histiocytosis X is a rare granulomatous disease and it is still under debate as to whether this disease has to be counted among malignant tumors or benign immunologic lesions. The typical localization is confined to the bone. In rare cases histiocytosis X may be localized in the oropharyngeal mucosa. PATIENTS AND METHODS: We report about a case of a 75-year-old woman presenting with histiocytosis X lesions solely located in the oral cavity. A total dose of 19.5 Gy was administered without any side effects. RESULTS: Two weeks after completion of irradiation a rapid regression of mucosal ulcerations and improvement of symptoms occurred. In a follow-up of 24 months the patient is still in complete remission observed. CONCLUSION: Review of the literature revealed only casuistic reports about solitary lesions of histiocytosis X without bone involvement in the adulthood. External beam radiotherapy with total doses between 10 and 20 Gy seems to be effective for local control of this disease.

The role of combination effects on the etiology of malignant nasal tumours in the wood-working industry.

Adenocarcinomas of the nose are regarded as an occupational disease in Germany and other European countries, and workers exposed to oak or beech wood-dust in the course of their work receive compensation if they incur adenocarcinoma of the nose. This has prompted a joint research project to record the functional and morphological changes of the nasal mucosa and/or paranasal sinus of 149 exposed subjects and 33 controls in accordance with a defined occupational exposure. To ensure the quantitative and qualitative reliability of the exposure data, 1,349 measurements at the company workplace were taken and analyses of 614 wood samples performed; parallel to this, the genotoxic effects of the most important substances used in the wood-working industry were tested. Apart from this, latency periods and morbidity rates in Germany were investigated. Partial findings of this research projects have been evaluated by the International Agency for Research on Cancer (IARC). According to these evaluations and the findings presented here, the following points can be made: i) Morphological changes in the nasal mucosa after exposure to wood-dust resulted in an increase in cylindrocellular hyperplasias and, in functional terms, a tendency towards improved nasal clearance was observed. Chromium and formaldehyde, on the other hand, tended to give rise to an increase in the number of squamous metaplasias. This might explain the preference for the histological types of adenocarcinoma among subjects exposed to wood-dust. ii) In tissue samples more dysplasias were found among those exposed to oak and beech wood-dust. Subjects exposed to wood preserving agents had dysplasias only if they were simultaneously exposed to oak and beech wood-dust. The latter effect did not quite reach the level of significance (p = 0.07) on account of the low numbers of cases. iii) The investigation of genotoxic effects showed that oak and beech contain genotoxic substances that can be dissolved by means of ethanol and cyclohexane; they also showed that 3 out of 8 wood preservatives, 5 out of 16 stains, and 2 out of 11 paints from the wood-working industry are genotoxic too. Apart from this, lindane and PCP have proved to be genotoxic in the nasal cells of rats and human beings. Analysis of 614 wood samples from wood-preserving agents showed that almost 73% contained agents of this type, even in woods described by the companies as being guaranteed free of wood preservatives. iv) According to an analysis of 147 cases accepted since 1985 as a pensionable occupational illness by the Holz-Berufsgenossenschaft (an industrial compensation society for employees in the wood-working industry), the disease was much more apparent in small companies where there is multi-factorial exposure, than in large companies where the exposure factor tends to have a single component. This points to the combined effects of hardwood dusts and chemicals as being the cause. v) According to published findings, the incidence of the disease in England seems to be on the decline. In Germany, increasing latency periods also point to a decline in the number of cases, although both countries have only very recently introduced effective prevention measures against exposure to wood-dust. This also leads to the assumption that wood-dusts cannot be the only cause of this type of cancer. vi) These findings tally with the evaluation by the IARC confirming the special part that hardwood dusts play in the development of nasal cancer. The findings presented here also indicate combined effects as being the cause of this type of cancer. This hypothesis cannot be confirmed until the conclusion of long-term animal experiments, currently being conducted, to test how the effects of chemicals such as lindane, PCP, and chromate compare with use of oak wood-dust.

[Surgery in benign parotid tumors: individually adapted or standardized radical interventions?]. / Chirurgie bei gutartigen Parotistumoren: Individuell angepasste oder standardisierte radikale Eingriffe?

BACKGROUND: Several authors demand emphatically that the minimal operative procedure in benign parotid gland tumors has to be a superficial parotidectomy. MATERIAL: Of a consecutive series of 372 patients with benign parotid tumors treated in our department between 1973-1996 81% of the patients could be followed up 1-24 years. in 10.9% a total parotidectomy was performed, in 16% a lateral parotidectomy and in 73.1% a simple extirpation of the tumor (often taking away a small margin of surrounding parotid parenchyma). The operating microscope and microsurgical techniques were used in all of these operations. RESULTS: Of all the followed-up patients 2.3% developed a recurrence. There were no recurrences of cystadenolymphomas or of rare types of adenomas. Recurrences of primary treated pleomorphic adenomas occurred in 3.0%. In recurrent pleomorphic adenomas a further recurrence could be seen in 7.4% of the cases. The over-all incidence of permanent facial nerve weakness was 2.1%: 0.7% after extirpation, 3.3% after lateral parotidectomy and 9.7% after total parotidectomy. we observed in 6.3% a gustatory sweating. CONCLUSION: Our data prove that with simple extirpation similar results compared to lateral parotidectomy can be achieved concerning recurrence, function of the facial nerve and the Frey's syndrome. We suggest a surgical management adapted to the extent, the size and the location of the parotid gland tumors. In our opinion lateral or total parotidectomy should be reserved for tumors of larger amount or deep located tumors.

[Endosonography of the pharynx]. / Endosonographie des Pharynx.

BACKGROUND: Endosonography is a diagnostic tool for the examination of tumors of the oral cavity. The pharynx is usually not assessable for conventional endosonography due to problems with the placement of the probe in deeper areas of the pharynx. PATIENTS: A fingertop ultrasonography probe was combined with a stick allowing the user to locate the probe in deeper areas of the pharynx. The stick had two flexible joints and a device for attaching the probe in the front. We evaluated 48 patients with tumors of the posterior wall of the pharynx (n = 6), lateral wall of the pharynx (n = 7), tonsil (n = 17), sinus piriformis (n = 13), and nasopharynx (n = 5) during preoperative tumor endoscopy under general anesthesia. Thirty-two patients suspected of having a tonsillar abscess were examined under local anesthesia. RESULTS: The evaluation of the tumor dissemination and the determination of the relationship between the tumor and the internal carotid artery was excellent for tumors of the posterior and lateral wall of the pharynx. The investigation of tumors of the sinus piriformis and the nasopharynx was difficult and tumor growth could not be determined normally with endosonography. In four cases, retropharyngeal lymph nodes could be detected. The sensitivity for the diagnosis of tonsillar abscesses was 84%. CONCLUSION: Endosonography of the deeper areas of the pharynx seems to be a useful instrument for investigating growth of tumors at the lateral and posterior wall of the pharynx. Endosonographic results might be helpful for deciding between endoscopic and external approaches. Endosonography is not sufficiently sensitive for diagnosing tonsillar abscesses, but might be helpful in clinically difficult cases.

Preformation of microvascular composite free flaps in the rat as an animal model.

For optimal reconstruction of large defects after tumor surgery of the head and neck, composite flaps may be necessary. We describe the design of microsurgically reanastomosed composite skin flaps, using porous polyethylene or titanium implants as a "back side" in an animal model. The epigastric skin of 48 healthy adult Wistar rats was prepared for the subdermal insertion of porous polyethylene implants (pore size: 100-200 microns) and titanium mesh implants having different forms and sizes. Two to 6 weeks after this procedure the flaps were lifted, transposed to the other side and the epigastric vessels were reanastomosed microsurgically. Eighty-three per cent of the skin flaps containing the titanium implants survived when the transplantation occurred 2 weeks after insertion of the implants. Concurrently all flaps with the implanted porous polyethylene (1 mm thick) showed signs of skin necrosis. Survival of the polyethylene loaded flaps improved to 50% when the flaps were left 4 weeks at the donor site. The influence of the implant form on the survival of the flaps was investigated with different implant shapes with flap necrosis being greatest when concave implants were used. Histopathological evaluation of the titanium flaps showed a thin capsule around the implants and a minimal inflammatory reaction. All porous polyethylene implants resulted in a pronounced chronic infection. Transplantation of flaps containing perforated metals (such as the titanium mesh) was possible 2 weeks after insertion of the implant, whereas neovascularization of flaps with porous material required more than 4 weeks growth in situ to ensure at least a 50% viability of the skin. An advantage of the metal implants is the possibility of its use in correcting form by modelling.

[Pharyngitis and its various clinical manifestations]. / Die Pharyngitis und ihre verschiedenen klinischen Erscheinungsformen.

Pharyngitis is one of the most frequent diseases of the upper aero-digestive-tract. The different kinds of inflammation of the pharynx are described with regard to etiology, clinical appearance and therapy.

[Possible applications for micro-plates in ENT surgery]. / Einsatzmöglichkeiten von Mikroplatten in der HNO-Heilkunde.

Microplates are smaller and more ductile than miniplates. We used microplates for fixation of fractures in children (seven cases), reconstruction of isolated frontal sinus wall fractures (39 cases), fixation of lateral mid-facial fractures (79 cases), fractures of the nasoethmoidal complex (14 cases), for different osteoplastic procedures (40 cases) and for laryngoplasty (three cases). Thirty fractures of the lateral mid-face were treated only with microplates. In these cases, reposition of the fractured bones was easily achieved and treatment was performed only a few days after the trauma. In 49 cases with unstable fractures after reposition, microplates and miniplates were combined for fixation. It is very important to assess the indications for different types of plates (miniplates or microplates) individually in every case. Because of the excellent biocompatibility of titanium and the low rate of local complications after internal fixation with microplates, it is usually not necessary to remove the plates.

[Should osteosynthesis plates in the area of the facial skull be removed again? Results of experimental and clinical studies]. / Müssen Osteosyntheseplatten im Gesichtsschädelbereich wieder entfernt werden? Ergebnisse experimenteller und klinischer Untersuchungen.

We discuss the arguments dealing with removal of fixation devices and plates after osteosynthesis of facial bone fractures. As an experimental model for examining the soft tissue reaction to implants under standard conditions, an inguinal flap was prepared in 24 Wistar rats. Titanium mesh implants (10 x 8 x 0.3 mm) were then inserted into the flaps. Twelve implants were additionally bent to investigate histologically the influence of mechanical preparation on tissue reactions. Examination of all specimens was carried out with the technique of Donath and showed a thin capsule around the titanium implants but without any signs of infection. Around the bent areas of the implants there were minimal signs of local chronic inflammation without a capsule. Use of titanium microplates instead of miniplates in 89 patients with midfacial fractures diminished the rate of local complications. Based on our experimental and clinical results, indications for the different types of plates and the necessity for their later removal are discussed. Our present plates are only removed from the maxillary sinus wall and the alveolar ridge, after osteosynthesis in children, and in patients with local complications. If removal of the material is planned (because of the location), less expensive steel implants are used.

[Prognostic significance of extra-capsular invasion in cervical lymph node metastases of squamous epithelial carcinoma]. / Die prognostische Signifikanz von Kapseldurchbrüchen bei Halslymphknotenmetastasen von Plattenepithelkarzinomen.

In a retrospective study we evaluated the clinical and histological datas of patients with squamous cell carcinomas of the head and neck to determine the influence of extranodal spread in metastases for the prognosis. Lymph nodes were dissected from the neck dissection specimens and investigated histologically with special regard to extranodal spread. 304 patients (58%) showed positive lymph nodes and 212 of this patients had additionally extranodal spread (70%). Hence, the rate of extranodal spread in the whole investigated group (522 patients) was 40%. For the patients with carcinomas of the hypopharynx the rate of extranodal spread was especially high (70%). Most extranodal spread could be found at levels 2, 3 and 4. We found a correlation between the appearance of extranodal spread and increasing T-stage. 5-year survival rates were greatly different for patients with no metastases (77%) and patients with extranodal spread (28%). We discuss the use of the criteria extranodal spread for the planning of adjuvant chemotherapy.

[Temporary sagittal mandibulotomy as an approach to the pterygopalatine fossa, the parapharyngeal space and the oropharynx]. / Temporäre sagittale Unterkieferspaltung zur Eröffnung eines Zuganges in die Fossa pterygopalatina, den Parapharyngealraum und den Oropharynx.

Standard procedures for temporary mandibulotomy are medial or the lateral osteotomy. Median mandibulotomy is associated with destruction of anatomical structures in the floor of the mouth and with lateral osteotomy no preservation of the nervus alveolaris inferior is possible. Therefore, a modification of mandibulotomy is described with wide-field exposure, minimal functional defects and reduction of osteotomy-related complications. The first osteotomy is carried out vertically before the foramen mentale on the buccal compacta of the mandible. A second vertical osteotomy is placed on the lingual compacta posterior to the musculus myohyoideus. Horizontal osteotomies on the alveolar ridge and the basal ridge of the mandible are connected with the vertical osteotomies. Using a chisel, the lingual and the buccal part of the mandible are split sagittally with preservation of the nervus alveolaris inferior located in the buccal fragment of the mandible. The two parts of the mandible are divided to provide access to the oropharynx. Surgical approach to the fossa pterygopalatina and the parapharyngeal space is reached with dissection of the mucosa along the ascending mandible, subluxation in the mandibular joint and reflection of the mandible cranially and posteriorly. The wide access offers a lot of advantages especially in combination with a microvascular flap reconstruction. Fixation of the mandible is carried out with two titanium miniplates at the anterior vertical osteotomy. The wide areas of the split bone marrow, resulting from sagittal splitting, achieved an exact adaptation of the mandibular parts and an easy and sure fixation via miniplates. Therefore, post-operative radiation therapy can be started two weeks after the operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasound in metastatic neck disease.

Statistical data have been collected from the literature concerning the value of B-scan sonography in detecting lymph node metastases in patients with different ENT malignancies. It is shown that up to now several attempts have been made in order to raise the specificity of ultrasound in this field. Some typical features of lymph node metastases are presented by showing their sonographic structures.