[Indications of intraoperative ultrasound in head and neck surgery]. / Indikationen für den intraoperativen Ultraschall bei Eingriffen im Kopf-Hals-Bereich.

BACKGROUND: A possible use of B-scan sonography arises from the difficulty in transferring information by means of imaging to the intraoperative situation, which is now possible with navigation systems in complicated surgical procedures in the field of otolaryngology. A solution to this problem offers the intraoperative use of ultrasonography for orientation in soft tissue surgery. PATIENTS AND METHOD: A prospective study involving 115 patients in total entailed scanning with a small part linear and fingertip probe with either 10 and 7.5 MHZ. An ultrasound endoscope featuring a 7.5 MHZ convex probe was used to image endolarygeal processes. RESULTS: Indications included panendoscopies, parotidectomies, submandibulectomies, lymph node exstirpations and abscess incisions. The colour doppler sonography was used in reconstructive surgery involving microvascular transplants. The display of soft tissue tumours provided information about tumour size as well as demarcation or infiltration of neighbouring structures. The fingertip probe and the ultrasound endoscopy served to evaluate areas that were morphologically difficult to access. After clamping the radial artery when harvesting the forearm flap, a sufficient perfusion of the thumb and later the sufficiency of the vascular anastomosis could be verified. CONCLUSION: The intraoperative use of sonography is an inexpensive non-invasive procedure that can be performed by the surgeon himself and allows quick and reliable orientation during difficult operations.

Clinical feasibility test on a minimally invasive laser therapy system in microsurgery of nerves.

The clinical feasibility test described here evaluates the basis for a laser therapy system that enables tumour tissue to be separated from nerves in a minimally invasive manner. It was first investigated whether, using an Er:YAG laser, laser-induced nerve (specifically, facial nerve) responses in the rabbit in vivo can be reliably detected with the hitherto standard monitoring techniques. Peripherally recordable neuromuscular signals (i.e. compound action potentials, CAPs) were used to monitor nerve function and to establish a feedback loop. The first occurrence of laser-evoked CAPs was taken as the criterion for deciding when to switch off the laser. When drawing up criteria governing the control and termination of the laser application, the priority was the maintenance of nerve function. Five needle-electrode arrays specially developed for this purpose, each with a miniature preamplifier, were then placed into the facial musculature instead of single-needle electrodes. The system was tested in vivo under realistic surgical conditions (i.e. facial-nerve surgery in the rabbit). This modified multi-channel electromyography (EMG) system enabled laser-evoked CAPs to be detected that have amplitudes 10 times smaller than those picked up by commercially available systems. This optimization, and the connection of the neuromuscular unit with the Er:YAG laser via the electrode array to create a feedback loop, were designed to make it possible to maintain online control of the laser ablation process in the vicinity of neuronal tissue, thus ensuring that tissue excision is both reliable and does not affect function. Our results open up new possibilities in minimally invasive surgery near neural structures.

Four years' experience with the minimally invasive surgical approach in cochlear implant surgery.

This is a prospective study on 808 profoundly or totally deaf patients who underwent either unilateral or bilateral cochlear implantation, involving a minimally invasive surgical approach, at the Medical University of Hannover's Department of Otolaryngology between May 2001 and May 2005. Advanced Bionics, Cochlear and MED-EL devices were used, the latter having been in use at our department since the beginning of 2003. The aim of our investigation was to determine the optimal surgical technique, evaluate safety aspects and gauge patient satisfaction with this minimally invasive surgical approach during cochlear implantation. Surgical technique is analysed. Complications such as skin flap problems did not occur. The use of this minimally invasive surgical technique did not increase the surgical risk. This procedure proved both cosmetically and psychologically beneficial for patients, especially for children and their parents.

[The value of dynamic posturography (Equitest) in preparing an expert's report]. / Der Stellenwert der dynamischen Posturographie (Equitest) bei gutachterlichen Beurteilungen.

BACKGROUND: Expert appraisals of vestibular disorders and their effects on daily life are essentially based on an evaluation of the patient's subjectively described symptoms. The aim of the present study was to ascertain the extent to which dynamic posturography is able to assist in the preparation of expert's reports. MATERIAL AND METHODS: 60 patients underwent a survey of their balance impairment. Both a nystagmus analysis, with its objective criteria, and dynamic posturography were carried out. The investigation into reduction of fitness for work (MdE) made reference to the criteria specified in the table by STOLL. The data obtained were subjected to both correlation and variance analysis. RESULTS: Although the results of this analysis revealed no direct statistical dependency, they indicated a tendency for the composite values to be correlated with the nystagmus scores and/or the MdE values (when the nystagmus score and/or the MdE increases, the composite value decreases). CONCLUSIONS: The Equitest is, according to the available data, not able to replace the currently valid MdE scores. Nevertheless, it represents a means of providing objective data about the vestibulo-spinal reflex. The test also reveals any tendencies towards simulation and aggravation. In the context of a specific nystagmus analysis, the Equitest offers an additional means of providing an objective background to back up the more subjective assessment of MdE.

[Vibrant Sound Bridge System. A new kind hearing prosthesis for patients with sensorineural hearing loss. 2. Audiological results]. / Vibrant Soundbridge System: Ein neuartiges Hörimplantat für Innenohrschwerhörige. Teil 2: Audiologische Ergebnisse.

OBJECTIVE: Implantable hearing aids present a new treatment modality for patients suffering from sensorineural hearing loss. The functional gain obtained with the partially implantable Symphonix soundbridge system was evaluated in a clinical study. The audiological results achieved with n = 34 patients over a period of up to three years are presented in this second part of the publication. PATIENTS AND METHODS: 34 patients have received the Symphonix Vibrant soundbridge system since February 1997. The average age at implantation was 47.2 years (minimum: 18.9 years; maximum: 80.3 years). All patients have had several years of experience with hearing aids, which, however, provided insufficient functional gain or could not be fitted with a conventional hearing aid for medical reasons (such as auditory ear canal problems). All patients fulfilled the audiological selection criteria as they had bilateral moderate to severe sensorineural hearing loss. As a rule, the ear with poorer performance was implanted. All patients were fitted with the audio processor eight weeks after the implantation. The pure tone thresholds, the functional gain, the monosyllable and sentence understanding (Göttinger Sentence Test in quiet and noise) were preoperatively and postoperatively assessed. Standardized self-assessment questionnaires were used to evaluate the subjective benefit (PHAB) and the quality of hearing (HDSS) as compared to the preoperative situation. Further hearing tests were performed after four weeks, three, six, nine, twelve, eighteen, twenty-four and thirty-six months postoperatively. During the observation period of up to three years the audioprocessor was updated several times, most recently with the fully digital three-channel-system Vibrant D. The results obtained were documented. RESULTS: Postoperatively, the pure tone threshold with the soundbridge system switched off did not change significantly in the implanted ear. All patients had a functional gain that was either comparable to the gain achieved with hearing aids or better. In particular speech-related frequencies showed improved amplification. The free field speech recognition tests revealed higher scores in quiet and in noise. The patients commended the natural sound quality, the lack of feedback, the absence of occlusion and distortion, the improved speech understanding in noise and the favourable cosmetic appeal. Only two patients failed to achieve better results as compared to their performance with conventional hearing aids. No complications, such as a deterioration of hearing due to inner ear damage or a conductive hearing loss, were observed in the long-term. CONCLUSIONS: The Symphonix Vibrant Soundbridge is a new and promising treatment modality for patients suffering from moderate to severe sensorineural hearing loss. Further improvement of the good results can be expected with improved coupling of the transducer to the ossicular chain and further development of signal processing.

[Skull base surgery with an opto-electronic navigation system]. / Schädelbasischirurgie mit einem optoelektrischen Navigationssystem.

BACKGROUND AND OBJECTIVE: The exact localization of pathological anatomy is the basis of a successful operation. Malformations, tumors, or previous operations can make intraoperative orientation considerably more difficult. Navigation systems can be useful tools in such cases. METHODS: The OTS is an optoelectrical navigation system which was used on 34 patients with disorders of the skull base region. Clinical accuracy, practicability, and intraoperative usefulness of the system were evaluated. RESULTS: In clinical use, an accuracy of approximately 1.5 mm could only be achieved with the use of head fixation and bone-anchored reference markers. When using the VBH mouthpiece for dynamic referencing with flexible head positioning, deviations of less than 2 mm were observed. The preoperative preparation time was 15-25 min, depending on the operation schedule. CONCLUSIONS: The intraoperative orientation system represents a significant aid for orientation, particularly where anatomical alterations are present. Further modifications to improve both accuracy and the integration of the system into working practice are, however, essential.

Safe electrical stimulation of the cochlear nerve at the promontory during functional magnetic resonance imaging.

The purpose of this study was to evaluate possibilities and technical risks for combining intended electrical stimulation of the cochlear nerve and functional magnetic resonance imaging (fMRI). Theoretical considerations and experiments indicate that fMRI can be performed safely during electrical stimulation. A nerve stimulator was developed with minimized length of electrical conductors, current limiting resistance, high inner impedance of a current source, radio frequency (RF)-shielding, and avoidance of ferromagnetic materials. This nerve stimulator transfers the optically encoded stimulating current signal via a fiber optic cable located near the area of stimulation. There, the optical signal drives an MRI-compatible current source. This set-up was tested with transtympanic electrical stimulation of the cochlear nerve at the promontory during an fMRI examination. No hazardous effects could be detected. The stimulation resulted in activation of the Heschl's gyrus. Compared to the conventional promontory testing this method may allow a more objective examination of cochlear implant candidates. Magn Reson Med 42:371-378, 1999.

[The Vibrant Soundbridge System: a new kind of hearing aid for sensorineural hearing loss. 1: Function and initial clinical experiences]. / Vibrant Soundbridge System: Ein neuartiges Hörimplantat für Innenohrschwerhörige. Teil 1: Funktionsweise und erste klinische Erfahrungen.

INTRODUCTION: Patients suffering from moderate to severe cochlear hearing impairment can not be considered for cochlear implantation on account of their relatively good residual hearing. Conventional hearing aids, on the other hand, have considerable disadvantages which clearly limit the benefit for these patients, e.g. feedback, sound distortion, unfavorable conditions for frequency transfer, occlusion, and recurrent infections of the auditory canal. In addition, many patients complain about a poor speech intelligibility in noise. VIBRANT SOUNDBRIDGE HEARING PROSTHESIS: Implantable hearing aids offer a new approach for improved auditory rehabilitation. The Vibrant Soundbridge system is based on an electromagnetic system, which is linked directly to the intact ossicular chain. Due to the high sound quality and the high frequency characteristic this system is ideally suited for the above-mentioned patient group. The usual disadvantages of conventional hearing aids can be avoided. Externally visible is merely the audio processor, which is worn in the retroauricular area and covered by hair. This processor transfers data and power via magnetic attachment transcutaneously. PATIENT POOL: During a European multicenter clinical study, 19 patients were implanted at MHH since February 1997. No significant complications occurred. RESULTS: In all patients, postoperative unaided pure tone threshold was unaltered in comparison with the preoperative recordings. The use of the audio processor leads to a significant functional gain, particularly in the high frequencies. The patients report about undistorted hearing resulting in a better speech understanding even in situations with loud background noise. CONCLUSION: The preliminary results show a promising new approach to the use of hearing prostheses for patients suffering from moderate to severe sensorineural hearing loss.

[Patients with trauma-induced deafness--rehabilitation using a cochlear implant]. / Traumatisch ertaubte Patienten--Rehabilitation mit Hilfe eines Cochlear Implants.

Deafness due to bilateral temporal bone fractures is a dramatic consequence for the injured patients. Out of more than 1000 patients in Hannover which received a cochlear implant we analyzed the medical history of 44 patients (36 male, 8 female, average age of adults: 41 years) which were implanted after posttraumatic deafness (Nucleus device n = 33, Clarion device n = 11). Postoperatively the patients underwent an auditory rehabilitation program. Most of them (84%) reached open set speech understanding. Results are different caused by additional damage of auditory nerve fibers and posttraumatic central lesions. Due to the risk of posttraumatic fibrosis of the cochlea, implantation should be performed early and can be recommended to the patient if bilateral deafness is diagnosed. In the case of auditory nerve damage brain stem implants offer new possibilities.

Regulation of diacylglycerol kinase reaction in Swiss 3T3 cells. Increased phosphorylation of endogenous diacylglycerol and decreased phosphorylation of didecanoylglycerol in response to platelet-derived growth factor.

We studied the influence of platelet-derived growth factor (PDGF) on diacylglycerol phosphorylation in Swiss 3T3 cells. Rates of incorporation of 32P into phosphatidic acid (PA) and phosphatidylinositol (PtdIns) were determined in prelabeled cells into which sn-1,2-didecanoylglycerol (diC10) had been introduced. PDGF stimulated the formation of [32P]PA and -PtdIns from endogenous substrates but decreased the formation of [32P]PA10 and -PtdIns10. Direct measurements of diacylglycerol phosphorylation in lysates of quiescent and stimulated cells showed that PDGF stimulated the phosphorylation of endogenous diacylglycerol 2-fold in parallel with diacylglycerol accumulation but decreased by 50% the phosphorylation of diC10. Total diacylglycerol kinase activity, measured in a mixed micellar assay, was not changed by PDGF treatment. The maximum activity of diacylglycerol kinase exceeded that needed to phosphorylate all of the endogenous diacylglycerol, suggesting that the PDGF-dependent increase in diacylglycerol mass would account for the increase in PA formation. The increased mass of diacylglycerol also could explain the inhibition of diC10 phosphorylation, via substrate competition. The predominant species of endogenous diacylglycerol was 1-stearoyl-2-arachidonoyl-glycerol (18:0/20:4 diacylglycerol). In mixed micelles, the rate of phosphorylation of 18:0/20:4 diacylglycerol was 8-fold higher than that of diC10, and the 18:0/20:4 species competed with diC10 for phosphorylation. Studies showed that a membrane-bound enzyme accounted for the PDGF effect on PA formation; there was no evidence for translocation of cytosolic enzyme to the membrane. The results support these conclusions: 1) PDGF stimulates the phosphorylation of cellular diacylglycerol by promoting a transient accumulation of this lipid. 2) The stimulated phosphorylation is catalyzed by a diacylglycerol kinase that preferentially phosphorylates 18:0/20:4 diacylglycerol over diC10. 3) The diacylglycerol kinase responsible for the PDGF effect is membrane-bound.

A membrane-bound diacylglycerol kinase that selectively phosphorylates arachidonoyl-diacylglycerol. Distinction from cytosolic diacylglycerol kinase and comparison with the membrane-bound enzyme from Escherichia coli.

The membrane-bound diacylglycerol kinase from Swiss 3T3 cells (M-DG kinase) was characterized with a mixed micellar assay system, and compared with the cytosolic diacylglycerol kinase from 3T3 cells and with the membrane-bound diacylglycerol kinase from Escherichia coli. M-DG kinase selectively phosphorylated arachidonoyl-diacylglycerols, at a rate 2- to 8-fold higher than that for other naturally occurring long-chain diacylglycerols. In contrast, the cytosolic 3T3 enzyme exhibited little or no selectivity among long-chain diacylglycerols but had higher activity with more soluble substrates such as 1,2-didecanoylglycerol. Comparison of the properties of M-DG kinase with those of the bacterial membrane-bound enzyme revealed that selectivity for arachidonoyl-diacylglycerol was unique to the mammalian enzyme. All three kinases were activated by phosphatidylserine, but activation did not alter the arachidonoyl selectivity of M-DG kinase. Phosphatidylserine activated M-DG kinase by increasing Vm and decreasing the apparent Km for diacylglycerol. High concentrations of diacylglycerol reduced the Ka for phosphatidylserine, but did not abolish the phosphatidylserine requirement for maximum activity. Examination of the thermal lability of M-DG kinase revealed that this enzyme was rapidly and selectively inactivated by preincubation with its preferred substrate. This novel effect may have obscured previous attempts to discern substrate selectivity. Taken together, the results provide evidence that M-DG kinase is an arachidonoyl-diacylglycerol kinase that may participate in the formation of arachidonoyl-enriched species of phosphatidylinositol.

Regulation of phosphoinositide phosphorylation in Swiss 3T3 cells stimulated by platelet-derived growth factor.

The regulation of phosphoinositide phosphorylation was studied in Swiss 3T3 cells that were stimulated by platelet-derived growth factor (PDGF). Studies with intact cells showed that the mitogen increased the incorporation of 32P into phosphatidylinositol (PtdIns), phosphatidylinositol 4-phosphate (PtdIns-P), and phosphatidylinositol 4,5-bisphosphate (PtdIns-P2) during the cell cycle, with distinct peaks of incorporation for all three phosphoinositides after 1 h, and for PtdIns and PtdIns-P2 after 20 h. Direct measurements of the activities of PtdIns kinase and PtdIns-P kinase in freeze-thawed cells revealed that the activity of PtdIns kinase was rate-limiting for the synthesis of PtdIns-P2. Maximal activities of PtdIns kinase and PtdIns-P kinase, with exogenous substrates, were unchanged during the 1st h of PDGF treatment, but doubled during the next 24 h. The increase in PtdIns kinase activity began within 2-4 h, exceeded the increase in cell protein, and was abolished by cycloheximide, which suggests that the enzyme was induced specifically in response to PDGF. The increase in activity of PtdIns-P kinase paralleled the increase in cell protein. Dose-response curves for PDGF showed that the activities of PtdIns kinase and PtdIns-P kinase at 24 h increased in proportion to the extent of mitogenic stimulation of the cells. Our results support the conclusion that the activities of PtdIns kinase and PtdIns-P kinase increase in response to PDGF, but only after several hours of cell cycle traverse.