[Case report of granulomatous necrotizing sialadenitis. Rarity of first manifestation in submandibular gland]. / Fallbericht einer granulomatös-nekrotisierenden Sialadenitis. Rarität einer Erstmanifestation in der Glandula submandibularis.

This article presents the case of a 43-year-old male patient with recurrent painful swelling of the right submandibular gland. Submandibulectomy was performed. Histological investigations showed an intense granulomatous inflammation with severe destruction of the parenchyma. The inflammatory infiltrate consisted of abscesses with neutrophilic and eosinophilic granulocytes and ill-defined granulomas with multinucleated giant cells. Some of the blood vessels showed evidence of vasculitis. After further clinical and serological investigations with highly elevated levels of cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA) and antiproteinase-3 antibodies, a rare limited disease of granulomatous polyangiitis (Wegener granulomatosis) was finally diagnosed. Such a manifestation of the disease is exceedingly rare; therefore, only single case reports have so far been described. The certain establishment of the diagnosis seems to be challenging because of the lack of involvement of the respiratory tract and the kidneys. In this case a histological assessment and clinical findings are mandatory for the correct diagnosis.

Carcinoma of the external auditory canal and middle ear.

PURPOSE: To evaluate therapeutic modalities used at our institutions regarding local control, disease-free survival and actuarial survival in carcinoma of the external auditory canal and middle ear, in an attempt to provide guidelines for therapy. METHODS AND MATERIALS: A series of 27 patients with carcinoma of the external auditory canal and middle ear treated between 1978 and 1997 in our institutions were analyzed with particular reference to tumor size and its relation to surrounding tissues, patterns of neck node involvement, surgical procedures, and radiation techniques employed. Clinical endpoints were freedom from local failure, overall survival, and disease-free survival. The median follow-up was 2.7 years (range 0.1-17.9 years). RESULTS: Treatment by surgery and radiotherapy resulted in an overall 5-year survival rate of 61%. According to the Pittsburgh classification, the actuarial 5-year survival rate for early disease (T1 and T2 tumors) was 86%, for T3 tumors 50%, and T4 stages 41%. Patients with tumors limited to the external auditory canal had a 5-year survival rate of 100%, patients with tumor invasion of the temporal bone 63%, and patients with tumor infiltration beyond the temporal bone 38%. The rate of freedom from local recurrence was 50% at 5 years. Unresectability by dural and cerebral infiltration, and treatment factors such as complete resection or resection with tumor beyond surgical margins are of prognostic relevance. All patients with dural invasion died within 2.2 years. The actuarial 5-year survival rate of patients with complete tumor resection was 100%, but 66% in patients with tumor beyond surgical margins. 192Iridium high-dose-rate (HDR) afterloading brachytherapy based on three-dimensional computed tomography (3D CT)-treatment planning was an effective tool in management of local recurrences following surgery and a full course of external beam radiotherapy. CONCLUSION: Surgical resection followed by radiotherapy adapted to stage of disease and grade of resection is the preferred treatment of cancer of the external auditory canal and middle ear.

Histological findings in sutured and fibrin-glued microvascular anastomosis.

A new method of microvascular anastomosis is presented. A sufficient sutureless telescoping anastomosis was achieved using fibrin adhesive (Tissucol, Immuno GmbH, Heidelberg, FRG) and a Fogarty embolectomy catheter (American Hospital Supply, Deutschland GmbH, Munich, FRG) as an internal splint in the abdominal aorta of Sprague-Dawley rats. The main advantage of this technique is its short application time. Histological examinations mostly showed accelerated healing compared with sutured anastomosis.

[Bilateral tympanic membrane perforation caused by a lightning accident]. / Beidseitige Trommelfellperforation durch Blitzschlagunfall.

Electrical damage of the ear can be caused by lightning or by electricity. A 41 year old woman hit by lightning causing burns and rupture of both tympanic membranes is reported and analysed.

[Allergic rhinitis in childhood--therapy and therapeutic success in a 5-year observation period]. / Allergische Rhinitis im Kindesalter--Therapie und Therapieerfolg über einen Beobachtungszeitraum von 5 Jahren.

An "infection allergy" must always be taken into account in children with allergic rhinitis, suffering from adenoids and also from recurrent rhinosinusitis. First of all, it would be necessary to take measures to cure the infection. Brief and mild symptoms only are no indications for hyposensitisation in definitely predominant allergy. Subcutaneous hyposensitisation proves more successful than oral hyposensitisation in children with severe signs and symptoms of allergy.

Immunological aspects of tonsils and of tonsillitis.

The human tonsils are responsible for the final antigen-induced differentiation of B-cells to plasma cells. Their main function could be the expansion of memory IgA-B-cells, allowing J-chain expression and final differentiation under secondary signals. IgA/J+-cells have been shown to migrate into mucosal membranes, allowing a protection against microorganisms. Recurrent tonsillitis obviously interferes with this complex immunological network, possibly resulting in a reduced mucosal protection by IgA. Furthermore, bacterial antigens can initiate the liberation of biochemical inflammatory mediators. Among these, arachidonic acid products can play a key role. They can induce epithelial damage and decreased ciliary function. Furthermore, they influence tonsillar immunological reactions.

[Fractures of the central midface and frontal skull base--surgical management--postoperative care--possibility of complications]. / Frakturen des zentralen Mittelgesichts und der Rhinobasis--operative Versorgung--postoperative Nachsorge--Komplikationsmöglichkeiten.

Mini-plate osteosynthesis is an osteoplastic procedure that achieves secure stabilisation of the midface even in extensive fractures of the midface and the floor of the anterior cranial fossa. This procedure can be considered as a satisfactory operative treatment both from a cosmetic and from a functional point of view. Nevertheless the partial loss of previous mucosa, and the development of granulation tissue and scar tissue can impede ventilation and drainage of the paranasal sinuses and induce recurrent inflammation. In the last five years we have treated 73 patients with extensive fractures of the midface and the anterior skull base, generally with good results. Aspects of the primary operative treatment, complications and post-operative care are discussed.

[The central branches of the anterior and median cerebral artery]. / Uber die Rami centrales der Aa. cerebri anterior und media.

1. In our examined subjects, the A. recurrens anterior was found to be more frequently doubled than as has been reported. 2. The number of central rami arising from the A. cerebri media varies between 3 and 13. 10% of these already divide extracerebrally so that the number of small asts actually present lies between 4 and 20. The count presented by Lazorthes appears to be based on the former method and by Jain on the latter. The ramifications arise from the main artery as well as from its insular branches. Arterial trunks are likewise often present that give off a large portion of the asts. When operating aneurysms of the A. cerebri media, these facts are of importance to the neurosurgeon who must sprare these vessels whenever possible. Should more of these branches or one of these arterial trunks be bound with a clip, serious neurological deficits will occur.

[Familial recurrent laryngeal nerve paralysis, a genetically fixed syndrome -- additional remark on linkage of deficiency gene and HLA (author's transl)]. / Die familiär gehäufte Rekurrensparese ein genetisch fixiertes Syndrom -- erneut Hinweise für eine Kopplung des Defektgens mit dem HLA-System.

Hereditary laryngeal paralysis has been rarely reported. Some authors describe additional neurological signs in connection with the cranial nerve, or mental retardation. It has been assumed that there is a causal connection with genetic deficiency. Familial studies, presented with this article, showed abductor and adductor paralysis in the mother and in the son, aged 13, abductor paralysis in the daughters, who were 11 and 5 years old, respectively, and normal laryngeal function in the father and in one 10-year old daughter. There were no neurological signs or mental deficits in any member of the family. Genetic analysis of blood-group and HLA systems confirmed linkage of the HLA system and vocal cord disorder, as suggested by Mace et al. (5). Hence, further observations and investigations will be necessary to prove this statement.

Anatomical studies and a correlative management of facial skeleton and skull base injuries with bone plate fixation.

Miniplate osteosynthesis is an osteoplastic procedure that achieves secure stabilization of the midface, even following extensive fractures of the midface and the floor of the anterior cranial fossa. This procedure can be considered a satisfactory operative treatment in terms of cosmetic and functional results. Correlative osteology is discussed and clinical experiences are reviewed.

[Injury of the interorbital space: II. Therapy. Pathology and therapy of the traumatic telecanthus]. / Das Trauma des interorbitalen Raumes: II. Teil: Therapie. Pathologie und Therapie des traumatischen Telekanthus.

The surgical treatment of lesions of the interorbital area belongs to the field of the rhinologist. Treatment options have been extended in recent years by technical advances. These include the extension of microsurgery to the base of the skull and the use of fibrin tissue glue. We have also had experience of an osteosynthetic material. Stable fixation of the antero-lateral walls of the interorbital space have esthetic advantages and functions as compared with interosseous wiring. An abutment is formed to support the upper jaw, and, with this, circular periorbital bony reconstruction is achieved.

[Polyvinylpyrrolidone granuloma--differential diagnosis of rare soft tissue tumors in the area of the maxilla]. / Polyvinylpyrrolidon-Granulom, zur Differentialdiagnose seltener Weichteiltumoren der Oberkieferregion.

A 68 year old woman with a polyvinylpyrrolidone-granuloma is presented. This rare tumour was seen after local injections of Depot-Impletol. Since we learned that PVP can produce such local tumours we have seen six cases. The clinical and histological diagnosis is very difficult, and may easily be confused with malignancy.

[Piriform sinus fistulas as rare hypopharyngeal abnormalities, diagnosis and therapy]. / Sinus-piriformis-Fisteln als seltene Hypopharynxmissbildung Klinik, Diagnostik und Therapie.

We report on the history, clinical findings, diagnostic examinations and the therapy of three patients with a left piriform sinus fistula, probably a fourth pharyngeal pouch. Our patients show recurrent inflammation and abscesses of the left lateral neck. X-ray (gastrografin swallow) showed the fistula originating from the floor of the left piriform sinus. CT-scan was helpful in the previously operated area, although the fistula could be shown by ultrasonic examination. Recurrent abscesses of the lateral neck may be caused by sinus piriform fistula. It is important to search for this rare malformation of the lateral neck.

[One-stage reconstruction of intraorbital fractures by means of plate osteosynthesis (author's transl)]. / Die Primärversorgung des zentralen Mittelgesichtspfeilers mit stabiler Plattenosteosynthese.

Considering the multiplicity of sequelae of central midface fractures (rhinoliquorrhea, anosmia, impediment to the drainage of the superior sinuses and to the lacrimal fluid, traumatic telecanthus, dish-face etc.) the importance of rhinosurgical treatment as the foremost procedure is shown. The small-fragment sets according to Champy as stabilizing elements in operations of the interorbital space (Converse) and its osseous supports are mentioned. Both the technical and the functional advantage of establishing a stable osseous trajectory in the rhinobasis after fractures is emphasized. Stable osteosynthesis as a primary therapeutic procedure enables the rhinosurgeon to find a remarkable synthesis of both functional and aesthetic tasks in this problematic area. The stable fixation makes the rhinosurgical treatment a preliminary one for other surgical procedure to follow.

[Therapy of sinusitis in childhood]. / Zur Therapie der Sinusitis im Kindesalter.

Therapy of sinusitis in childhood should be adapted both to various kinds and degrees of inflammation and to the age of the child. Furthermore, aetiology and pathology of the disease should also be taken into account. Especially in chronic disease, an allergy could be the cause; therefore, one should initiate suitable investigations and start adequate treatment. As with all long-term therapy measures, it is essential to persuade both the child and the parents to participate in the treatment and to get their co-operation.

Free-flap reconstruction for laryngeal preservation after partial laryngectomy in patients with extended tumors of the oropharynx and hypopharynx.

Partial laryngeal resection often results in major aspiration problems, making larynx preservation during surgical removal of tumors of the oropharynx and hypopharynx impossible. However, free flaps can be used to reconstruct perilaryngeal tissue, thus preserving the larynx and ensuring a better quality of life for patients. We present the results of forearm free-flap reconstruction of the supraglottis in 22 patients who underwent resections of extended squamous cell carcinomas of the oropharynx and hypopharynx. A total of 9 patients had T3 lesions and 13 had T4 lesions. All patients were additionally treated with radiation therapy alone (to 70 Gy) or in combination with chemotherapy (Cisplatin; 5-fluorouracil). The mean follow-up was 2.4 years. In four patients, tracheostomy could be closed. Five patients suffered from severe aspiration, one of whom had to undergo a laryngectomy. Six patients had mild aspiration and 7 patients had no aspiration, but extensive edema made decanulation impossible. A total of 13 patients were free of disease, 4 patients died of disease, 1 patient died as the result of a second primary cancer and 1 patient died of other causes. Three patients are alive with persistent tumor. Although the majority of patients experienced a better quality of life as a result of larynx preservation, aspiration has remained a problem following treatment.

[Outcome after resection of extensive oropharyngeal carcinomas and defect coverage by microvascular anastomosis of a radialis flap]. / Ergebnisse nach Resektion ausgedehnter Oropharynxkarzinome und Defektdeckung durch den mikrovaskulär anastomosierten Radialislappen.

BACKGROUND: Extensive tumors of the oropharynx require an open approach and plastic reconstruction for good oncologic and functional results. PATIENTS AND METHODS: From January 1988 through December 1996 at the Department of Otolaryngology, Head and Neck Surgery, of the University of Würzburg, 62 patients with extensive tumors of the oropharynx underwent surgical treatment (T2 = 6, T3 = 24, T4 = 32). In 40 patients, the resection was performed via a median mandibulotomy approach, in 22 patients using a lateral pharyngotomy. All patients underwent postoperative radiotherapy up to 70 Gy. RESULTS: Using the Kaplan-Meier method, the five-year survival was 80% for T2, 52% for T3, and 22% for T4. Four patients (7%) presented with a second primary carcinoma, and one also had a third carcinoma. Seven patients who died of T3- and T4-tumors had distant metastases, among them 5 patients who were free of local disease. A regular oral diet was possible on average 14 days postoperatively. All patients underwent tracheostomy. Ninety percent of them were decanulated one year postoperatively. CONCLUSIONS: Resection of extensive carcinomas of the oropharynx and microvascular reconstruction produces good oncological and functional results. The best access to extensive tumors is provided by a mandibulotomy. The advantage of this excellent approach outweighs an increasing morbidity in occasional cases.