Facial reconstruction with a unique osteomyocutaneous DCIA perforator flap variant: a case report.

BACKGROUND: Anatomical variance of the deep circumflex iliac artery is of high clinical value in facial reconstruction using a deep circumflex iliac artery perforator (DCIAP) flap. METHODS: We present the case of a 76-year-old woman treated with an osteomyocutaneous DCIAP flap variant for facial reconstruction. We also review here the literature on DCIA perforator flaps and the different anatomical variances, which might bring clinical benefits. RESULTS: The observed anatomy in our patient offered the possibility to raise a free flap variant with high mobility of a large skin paddle and a long vascular pedicle combined with a variable osteomuscular portion. CONCLUSION: The characteristics of the flap thus raised help overcome the disadvantages of the conventional DCIAP flap and offer excellent options for facial reconstruction.

[The anterolateral thigh flap: its versatility in oncological soft tissue reconstruction of the head and neck region]. / Der anterolaterale Oberschenkellappen : Seine Vielseitigkeit bei der onkologischen Weichteilrekonstruktion im Kopf-Hals-Bereich.

The anterolateral thigh flap (ATL) has become a standard procedure in reconstructive microsurgery. In this study the results with the ALT for reconstruction in the head and neck area after tumor resection in 33 patients were retrospectively analyzed. Patients included 28 men and 5 women aged 47-70 years who suffered from intraoral and extraoral tumors. Satisfactory soft tissue coverage could be achieved in all patients and no flaps were lost. The ALT is a versatile free flap enabling reliable soft tissue reconstruction of complex defects in the head and neck region. Flap dissection and preparation of the recipient area can usually be performed simultaneously. Additional advantages include the long and strong caliber vascular pedicle, the low donor site morbidity and the different possibilities of tissue composition, making the ALT a workhorse flap in modern reconstructive microsurgery.

Flexible versus rigid endoscopy for treatment of foreign body impaction in the esophagus.

BACKGROUND: The use of either flexible endoscopy (FE) or rigid endoscopy (RE) for removal of ingested foreign bodies (FBs) impacted in the esophagus is still discussed controversially. METHODS: We report a consecutive series of 139 patients with FB impaction in the esophagus. During a 6-year period, 69 men and 70 women (median age, 64 [0.7-97] years) requiring removal of an impacted FB underwent either RE (n = 63) in the Otolaryngology Department of our hospital or FE (n = 76) in the Surgical Endoscopy Unit. RESULTS: Foreign body removal was equally effective with FE (success rate 93.4%) and RE (95.2%, p = n.s.). The cases in which foreign body removal failed (5 FE cases [6.6%] and 3 RE cases [4.8%]) were all subsequently successfully managed with "conversion" and use of the other technique. No severe complications occurred when FB removal was attempted with FE (0 of 76 cases; 0.0%), whereas RE was associated with esophageal rupture requiring immediate surgical intervention in 2 of 63 cases (3.2%; p < 0.002). Patient comfort differed significantly between the two procedures (p < 0.0001); RE was always performed under general anesthesia (100.0%), whereas only a minority of patients undergoing FE required general anesthesia (13.0%; p < 0.0001) or mild analgosedation (20.0%). The better patient comfort with FE was also reflected in a significantly lower rate of dysphagia (15%) compared to RE (48%; p < 0.0001). Rigid endoscopy was more frequently used in removal of FBs of the upper esophagus (p < 0.0001), whereas FE was the predominate approach to FBs in the lower esophagus (p < 0.0001). CONCLUSIONS: A tailored approach to treatment of FB impaction is recommended. Because of the lower rate of severe complications, better patient comfort with a lower rate of dysphagia, and lack of requirement for general anesthesia, FE should be the "first line" approach to FBs, although RE has its place as the "second line" therapy.

Subacute fatal aluminum encephalopathy after reconstructive otoneurosurgery: a case report.

We report a 52-year-old woman who underwent otoneurosurgery to resect acoustic neurinoma. Bone reconstruction was performed with an aluminium (Al)-containing cement. Six weeks later the patient suffered from loss of consciousness, myoclonic jerks, and persistent grand mal seizures, clinical symptoms that resembled those of lethal dialysis encephalopathy of the 1960s and 1970s. She died 6 months later because of septic complications. Light- and electron-microscopic investigation of the central nervous system (CNS) showed pathognomonic Al-containing intracytoplasmic argyrophilic inclusions in choroid plexus epithelia, neurons, and cortical glia. These changes are characteristics of dialysis-associated encephalopathy (DAE), induced nowadays by long-term ingestion of Al-containing drugs (and with benign clinical courses). Atomic absorption spectrometry showed an increase of mean bulk Al concentration of the cortex and subcortex up to 9.3 microg/g (normal range <2 microg/g); laser microprobe showed the increase of Al in subcellular structures. This unique case again shows the extraordinary neurotoxicity of Al, which was, in our patient, initiated by an amount of about 30 mg Al and apparently caused by direct Al access to the brain parenchyma via a cerebrospinal fluid leakage.

Reanimation of the paralyzed face with new gold weight implants and Goretex soft-tissue patches.

Although dynamic reconstruction procedures are preferred for treating patients with complete facial paralyses, static procedures are useful for various conditions. One such technique involves the implantation of gold weights into the upper eyelid. We have reported our experiences with 58 patients who underwent gold weight implantation for rehabilitation of eyelid closure with satisfactory results. To obtain better cosmetic results we developed newly shaped thinner weights. Four instead of three perforations in each weight enable better fixation to soft tissue. Since 40% of all cases also required additional surgery to rehabilitate other portion of the face, polytetrafluoroethylene (Goretex) soft-tissue patches were used for suspension to help correct midfacial and perioral asymmetry. From 1990 to 1996, 22 patients underwent this technique under local or general anesthesia. Except for 2 patients, no complications were observed. Overall, both gold implants and Goretex patches were found to provide good results in patients selected for facial reanimation.

[Otosclerosis--diagnosis and therapy]. / Otosklerose--Diagnose und Therapie.

Otosclerosis (synonym: otospongiosis) is a focal or diffuse spongifying disease of the bony labyrinth. So far pathogenesis is unknown, some recent investigations assume a paramyxovirus infection. But there are no doubts about hereditary and genetic factors, females are twice often affected as males with a maximum incidence between 20 and 40 years. If the disease invades the oval window niche it causes fixation of the stapes with conducting hearing loss. In some cases otospongiosis is associated with and presumably causes cochlear degeneration alone with sensoneurale hearing impairment of varying degree. The surgical technique is now well developed and the operative treatment enables in over 90% a closure of the air-bone gap by using stapes pistons. The medical therapy in cases of sensoneural hearing loss with sodium fluoride is still controversially discussed.

[Acute otitis media. Current therapeutic and clinical aspects]. / Die akute Mittelohrentzündung. Aktuelle therapeutische und klinische Aspekte.

Otitis media acuta is defined as an acute inflammation of the pneumatic spaces of the temporal bone, that means the middle ear including the mucous membranes of the mastoid cells and of the Eustachian tube; it is caused mainly by bacteria, rarely by viruses. When treated properly by antibiotics, otitis media acuta heals in the rule within two to three weeks completely. If more than three episodes of otitis media occur within one year, the disease is called recurrent otitis media. Secretory otitis media (mucoserotympanon) may be proceeded by an otitis media acuta, but it can also develop without any fore-going disease. If the inflammation of the middle ear is quite symptomless, it is called an occult otitis media or an occult mastoiditis; the causes are often insufficient antibiotic therapies. In these cases an operative treatment (paracentesis, mastoidectomy, antrotomy, adenoidectomy, ventilating tubes) may be necessary. If the defense of the mucous membranes respectively of the whole body is weak or the antibiotic treatment insufficient, there may develop some other sequelae like chronic otitis media, atelectasis, otitis media chronica adhesive, tympanosclerosis, with or without development of cholesteatoma. The typical clinical symptoms, possible complications and the recommended antibiotic and physical treatment are referred.

[Itching following therapy with hydroxyethyl starch (HES) in otoneurological diseases]. / Juckreiz nach Therapie mit Hydroxyäthylstärke (HES) bei otoneurologischen Erkrankungen.

It is generally assumed, that a disturbance of microcirculation is the common pathogenetic end factor in various cochleovestibular disorders of different etiology. Therefore improvement of microcirculation is an important therapeutic goal. Several studies demonstrated, that hydroxyethylstarch (HES) has better haemorheological effects than Dextran and less side effects. For this reason we have changed the therapy with Dextran since 1987 to hydroxyethylstarch in several oto-neurological disorders (as sudden hearing loss, neuronopathia vestibularis, idiopathic facial palsy). As after the therapy with HES--generally after dismissal from the ENT-department--some patients complained of general pruritus, so we performed a retrospective study with a standardized interview-protocol. Of 481 treated patients we investigated 237 (49%): of 149 patients treated with HES 200/0.5, 43 patients (28.8%) complained of pruritus; from 88 patients treated with Dextran 40, only 5 patients (5.7%) reported pruritus. The difference is significant (p less than 0.0001). In nearly half of the patients (more than 40%) the pruritus started in normal skin 1 to 3 weeks after the HES-therapy and lasted for 6 weeks to 6 months; the itching was very resistant to therapy (f.e. with antihistaminics). We want to draw the attention to this possible, in the literature until now quite neglected, for some patients extremely uncomfortable and socially embarrassing side effects after HES-therapy when given in relatively high doses. It is therefore suggested therapeutic recommendations should be developed to prevent this undesired side effect.

[Muco-serous otitis media]. / Das Mukoserotympanon.

Typical symptoms of the otitis media with effusion (OME)--synonym (secretory otitis media--SOM)--are fluid (serous/mucoid) in the middle ear space and a conductive hearing loss. Its most incidence can be found in infants and kids, during this period often bilaterally, but also in adolescents and adults. Etiopathological factors are infections of the upper respiratory tract, obstructing adenoids, tumors of the nasopharynx, cleft palate patients, allergological and immunological influences. As most important anatomical factor ventilation problems, respectively insufficiency of drainage of the eustachian tube is considered. Especially in childhood, OME reveals high spontaneous remission. Thus in many cases is no need for treatment. Persists OME over a longer period (some months) or in patients with recurrent disease, therapy is necessary: decongestant nasal drops, local heat during concomitant upper air way infections, long term application of low dose antibiotics, adenoidectomy with myringotomy, or insertion of ventilating tubes.

[Sudden deafness--diagnosis and therapy]. / Der Hörsturz--Diagnose und Therapie.

Sudden deafness is defined as acute inner ear hearing loss, in the rule one-sided, of unknown etiology. The tentative diagnosis can be made easily by otoscopy and simple audiological forke tests. To exclude symptomatic acute hearing losses during the first treatment period, f.e. acoustic neurinoma, rupture of the round window membrane, multiple sclerosis, infectious diseases like Borreliosis or Lues, but also psychogenic hearing disorders we recommend an immediate hospitalization. Neurological and internal check up should look for inflammatory or degenerative diseases of the vascular or nervous system and also for metabolic risk factors like diabetes mellitus, hyperlipidemia, gout or blood hyperviscosity. Today there are some reasons to assume, that disturbances of the microcirculation of the cochlea end vessels may a possible prominent etiological factor in sudden deafness. Therefore the aim of therapy today is to improve the microcirculation and the oxygenation of the sensory cells of the inner ear.

[Pruritus--a side effect of hydroxyethyl starch? First report]. / Juckreiz--Eine Nebenwirkung von Hydroxyäthylstärke (HES)? Erste Mitteilung.

It is generally assumed that a disturbance of microcirculation is the common pathogenic pathway of various cochleovestibular disorders. Several studies have demonstrated that hydroxyethyl starch (HES) has better rheological effects than dextran 40, and fewer side-effects. Therefore, we changed from dextran 40 to hydroxyethyl starch in 1987 for the treatment of several otoneurological disorders. However, some patients complained of general pruritus after 1 or 2 weeks of therapy with HES. Therefore, a retrospective study was performed using a questionnaire of 491 patients treated for various cochleovestibular disorders. We received answers from 94 (20%): 25 of 59 (42.4%) patients treated with HES complained of pruritus compared with only 4 of 35 (11.4%) patients treated with dextran 40. The difference was significant (P less than 0.01). Critical points are the retrospective study design and the small number of patients, so that no conclusions can be drawn about the incidence of pruritus after therapy with HES. However, we would like to focus attention on this side-effect, which has been neglected in the literature but is extremely uncomfortable and socially embarrassing for some patients.

A map of cochlear perilymph protein based on high-resolution two-dimensional electrophoresis.

For systematic characterization of cochlear perilymphatic (PL) fluid proteins and to compare the complex protein mixtures of PL fluid, cerebrospinal fluid (CSF) and blood plasma, we subjected eight postmortem PL fluid samples to two-dimensional (2D) electrophoresis. To avoid contamination of perilymph by blood and blood plasma, the samples were taken immediately after death and analyzed by keeping to certain selection criteria. When compared with CSF, PL fluid in the scala vestibule was found to have an albumin content of approximately 1-2g/l, or 10 times the level of CSF albumin. Due to the small volume of the sample obtained, it was not possible to concentrate the PL fluid. As a result, protein spots in the 2D-gel could only be detected with a highly sensitive silver stain. Visual inspection of the resulting 2D-electrophoretograms showed that most of the "CSF-specific" protein clusters were present in the PL fluid pattern.

[Radiation dosage and clinical value of conventional tomography and high resolution computerized tomography of the nose and ear]. / Dosisbelastung und klinische Wertigkeit bei konventioneller Tomographie und HR-Computertomographie der Rhino-und Otobasis.

Hypocycloidal (frontal and temporal) tomography of the base of the skull is compared with high resolution computed tomography (HR-CT) with respect to dose and clinical usefulness. In most cases HR-CT is indicated because of its better density resolution in comparison with conventional hypocycloidal tomography. As the X-ray beam is directed at the slice plane the dosage is noticeably less than when using conventional tomography. Slice thickness depends on the required geometric resolution. This is an additional factor in radiation protection.

[Cerebrospinal otorrhea--cerebrospinal rhinorrhea. The Salzburg concept of cerebrospinal fluid diagnosis]. / Otoliquorrhoe--Rhinoliquorrhoe. Salzburger Konzept zur Liquordiagnostik.

The three following cerebrospinal fluid (CSF) examinations make it possible to identify even the smallest amounts of CSF in case of CSF otorrhoea and rhinorrhoea. 1. Immunological identification of beta 2-transferrin (Oberascher/Arrer) 2. Laboratory fluorescein identification (Oberascher/Arrer) 3. Endoscopic fluorescein detection according to Messerklinger. For screening, and as the method of choice, beta 2-transferrin identification is always used as a first step if there is a suspicion of liquorrhoea. Depending on the result and on further measures, both fluorescein tests are used additionally in diagnosis. Basing on practical experience gained recently, special attention is given to test analysis, the various possibilities of taking samples, and their means of transport or mailing. A newly developed diagnostic step-by-step plan is intended to emphasise the clinical significance by means of practical examples. This concept represents the present state of the art in CSF diagnosis and demonstrates that a much mor precise range of indication is possible in surgery of fractures of the base of the skull and CSF leaks if it is combined with an appropriate x-ray examination.

Protein distribution in the human perilymph. A comparative study between perilymph (post mortem), CSF and blood serum.

The large differences in the protein content of perilymph and serum as well as the perilymph volume limit of 10-15 microliter cause serious problems when collecting samples of uncontaminated perilymph in order to analyse its protein composition. In 8 out of 24 extremely carefully taken samples of perilymph removed during autopsy, we were able, by keeping to certain selection criteria, to carry out electrophoretic analyses which were suitable for reproduction and comparison. Comparison of human perilymph, CSF and serum, using SDS-Page and Western blotting, gave the expected agreement which had been suggested by tests on guinea pigs. However, a closer examination of individual proteins pointed to some relatively large differences in quantity and quality.

A modern concept of cerebrospinal fluid diagnosis in oto- and rhinorrhea.

Three successive CSF investigations make it possible to identify even the smallest amount of cerebrospinal fluid (CSF) in cases of otorrhea and rhinorrhea: 1. Immunological identification of beta 2-transferrin. 2. Laboratory fluorescein identification. 3. Endoscopic fluorescein detection. As a screening procedure the beta 2-transferrin identification method is always used as the first step towards clarifying a suspect liquorrhea. In addition both fluorescein tests are used for the diagnosis depending on the result of the beta 2-transferrin identification and further measures. As a result of recent practical experience special attention is paid to the test analyses; the various possibilities of taking samples as well as mailing them. A newly developed diagnostic plan of procedure should (by using practical examples) underline the clinical significance. This study describes the most up-to-date level in CSF diagnosis and demonstrates that, when combined with a corresponding X-ray investigation, a much more exact range of indication for the surgical treatment of fractures of the base of the skull and CSF leaks is possible.

[Dislocations and fractures of the ossicles--high resolution computerized tomography of the petrous bone]. / Dislokationen und Frakturen der Ossikula--HR Pyramiden Computertomographie.

As in traumatology of the head the HR-CT of the injured petrous bone is now the imaging method of choice. With axial and coronary slices one can show not only the different parts of the ear but also the course of the facial nerve and particularly the ossicles in the tympanon. The fractures are nice to show, also the soft tissue lesions like brainprolaps in the tympanon or hematotympanon because of the better density resolution in comparison to the conventional tomography with rather higher radiation dose especially for the eye lenses. Important are the slice thickness of 1.5 mm with special examination technique, that also small fractures of the pyramid particularly the labyrinthous organ and of the ossicles mostly associated with dislocations are detectable. Regarding that with the clinical possibilities there are particular consequences for the otosurgeon. The ossicular dislocations of other than traumatic cause are rare.