[Continuous intraoperative neuromonitoring (cIONM) in head and neck surgery-a review. German version]. / Kontinuierliches intraoperatives Neuromonitoring (cIONM) in der Kopf-Hals-Chirurgie ­ eine Übersicht.

Although the history of intraoperative neuromonitoring (IONM) dates back to the 19th century, the method did not evolve further than the mere differentiation of nerves until recently. Only the development of continuous IONM (cIONM) has allowed for non-stop analysis of excitation amplitude and latency during surgical procedures, which is nowadays integrated into the software of almost all commercially available neuromonitoring devices. The objective of cIONM is real-time monitoring of nerve status in order to recognize and prevent impending nerve injury and predict postoperative nerve function. Despite some drawbacks such as false-positive/negative alarms, technical artefacts, and rare adverse effects, cIONM remains a good instrument which is still under development. Active (acIONM) and passive (pcIONM) methods of cIONM are described in literature. The main fields of cIONM implementation are currently thyroid surgery (in which the vagal nerve is continuously stimulated) and surgery to the cerebellopontine angle (in which the facial nerve is either continuously stimulated or the discharge signal of the nerve is analyzed via pcIONM). In the latter surgery, continuous monitoring of the cochlear nerve is also established.

Continuous intraoperative neuromonitoring (cIONM) in head and neck surgery-a review.

Although the history of intraoperative neuromonitoring (IONM) dates back to the 19th century, the method did not evolve further than the mere differentiation of nerves until recently. Only the development of continuous IONM (cIONM) has allowed for non-stop analysis of excitation amplitude and latency during surgical procedures, which is nowadays integrated into the software of almost all commercially available neuromonitoring devices. The objective of cIONM is real-time monitoring of nerve status in order to recognize and prevent impending nerve injury and predict postoperative nerve function. Despite some drawbacks such as false-positive/negative alarms, technical artefacts, and rare adverse effects, cIONM remains a good instrument which is still under development. Active (acIONM) and passive (pcIONM) methods of cIONM are described in literature. The main fields of cIONM implementation are currently thyroid surgery (in which the vagal nerve is continuously stimulated) and surgery to the cerebellopontine angle (in which the facial nerve is either continuously stimulated or the discharge signal of the nerve is analyzed via pcIONM). In the latter surgery, continuous monitoring of the cochlear nerve is also established.

Regional recurrence in a case series of patients with carcinoma of the nasal cavity - therapeutic implications.

INTRODUCTION: Surgery is the primary treatment option for squamous cell carcinomas of the nasal cavity (NCSCC). Nodal involvement is rare at the time of initial diagnosis, and the role of diagnostic neck dissection as well as potential adjuvant irradiation of the neck remains controversial. The objective of this study was to assess the oncologic outcomes of patients with NCSCC with special emphasis on cervical lymph node treatment and recurrence. METHODS: 37 previously untreated patients were included in this study. Demographic data, tumor characteristics, therapeutic management, and clinical outcome were analyzed. RESULTS: Patients with advanced stage tumors were slightly overrepresented in this study and overall 3-year disease-free survival was 63%. A surgical treatment approach was pursued in 89% (n=33) of patients. After total rhinectomy, there were no cases of local recurrence. Overall, 12% (n=4) of all surgically treated patients developed local recurrence. While in 45% of patients (n=15), neck dissection was performed at the time of tumor resection, initial lymph node metastasis was histologically confirmed in only 6% (n=2) of surgically treated patients. Cervical lymph node recurrence occurred in 18% (n=6) of patients, predominantly those with advanced stage tumors, despite prior treatment of the neck. CONCLUSION: Excellent local control is achievable for patients with NCSCC, especially with radical tumor resection. While cervical lymph node metastasis is rare at the time of diagnosis, regional lymph node recurrence needs to be taken into consideration when planning therapy and follow-up. Multimodal treatment of the neck may be required for patients with advanced stage tumors.

[The Current Role of Salvage-Surgery of Recurrent Tumors in the Larynx and Pharynx]. / Aktueller Stand Salvage-chirurgischer Therapiekonzepte bei Rezidivtumoren des Larynx und Pharynx.

Over the past 20 years, the therapeutic concepts for the treatment of head and neck cancer have evolved and non-surgical treatment strategies have gained in importance. However, despite improved organ preservation protocols and primary chemoradiation, tumor recurrence is still frequent. Under these conditions, salvage surgery if often the only remaining curative treatment option. Over the past 30 years, advancements in plastic-reconstructive surgery have broadened the surgical spectrum in the head and neck area, offering new treatment options for salvage surgery in recurrent cancer of the pharynx and larynx. Survival after salvage surgery mainly depends on the primary treatment modality as well as the localization and tumor stage at the time of initial diagnosis and local recurrence. For the reconstruction of defects after salvage surgery, pedicled flaps and microvascular free flaps may be utilized. The most frequently used flaps in these situations are the pectoralis major island- or the myocutaneous latissimus dorsi island flap. The radial forearm and the ALT-flap are potentially applicable free flaps. With the use of these flaps, vital tissue is transferred into the previously irradiated area, hereby allowing for reconstruction and functional preservation of the resected area and preventing complications such as fistulas. The expected morbidity and the likelihood of surgical success must be assessed thoroughly in every individual case prior to performing salvage surgery. This review aims to support decision making in these situations.

[The use of a flexible CO2-laser fiber in transoral robotic surgery (TORS)]. / Der Einsatz einer flexiblen CO2-Laser-Faser in der transoralen Roboter-assistierten Chirurgie (TORS).

BACKGROUND: Recently transoral robotic surgery has gained importance in the resection of head and neck tumors, especially in North America. The available resection tools are a fiber guided Tm:YAG-laser and a monopolar cautery, both causing wide coagulation and vaporization zones in healthy tissue. In order to improve the cutting properties we combined the system with a flexible CO2-laser fiber. MATERIAL AND METHODS: 6 patients suffering from T1 and T2 oropharyngeal carcinomas were treated between July 2012 and September 2012. In a prospective study we analyzed the feasibility, cutting properties, speed of resection as well as hemostasis and compared those with the monopolar cautery and the Tm:YAG laser which were recently examined in a series of 17 patients. RESULTS: The application of a CO2-laser fiber with the da Vinci system was feasible and showed good cutting properties. Using a 15 watts energy level resulted in a favourable cutting depth and adequate hemostasis. In comparison to the monopolar cautery or the Tm:YAG laser, smaller coagulation and vaporization zones could be achieved. CONCLUSION: Cutting properties of the da Vinci system can be improved by using a flexible CO2-laser fiber. Further prospective evaluations will follow.

[Penetrating injuries of the head and neck region - a potentially life threatening situation]. / Penetrierende Verletzungen der Kopf-Hals-Region - Eine Potentiell Lebensbedrohliche Situation.

UNLABELLED: Penetrating Injuries of the Head and Neck Region - A Potentially Life Threatening Situation Background: Cuts, stabs and gunshot wounds in the head and neck region are potentially life-threatening because of the high risk of vascular lesions. A consistent emergency management is usually based on an operative exploration of the wound with effective reconstruction of viable structures. PATIENTS AND METHODS: Various penetrating injuries of the head and neck region are described in 11 cases with respect of age, gender, course of events of injury, type of injury, involved structures, diagnostic and operative procedures and outcome and compared with current literature and guidelines. RESULTS: In 10 of 11 patients, in the context of an interdisciplinary emergency room management, CT angiography was performed following clinical examination. A surgical exploration and wound treatment was performed in 9 of these patients. The common carotid artery, the external carotid artery and large venous blood vessels of the neck were injured in 2 cases respectively. None of the patients deceased or suffered permanent damage. CONCLUSION: The outcome of deep head and neck lesions with relevant vascular trauma is determined by a rapid and interdisciplinary approach. A rapid, systematic and interdisciplinary approach in specialized trauma centers has a significant role in ensuring that patients with penetrating wounds in the head and neck -region rarely die due to their serious injury or their consequences.

[The treatment of chronic wounds in the head and neck area after radiotherapy with medical honey]. / Die Behandlung chronischer Wunden im Kopf-Hals-Bereich nach Radiatio mit medizinischem Honig.

BACKGROUND: Wound healing problems and chronic wounds can be a therapeutic challenge are a frequent problem after radiotherapy. They can appear spontaneously or after further surgery. The permanently altered tissue is associated with recurrent bacterial infections with weeping wounds, which cannot be treated sufficiently by conventional conservative wound care. The topical application of medical honey seems to have a positive effect in such cases. The aim of this prospectively study is to check this effectiveness in the treatment of wound healing problems and chronic wounds in the head and neck area of irradiated patients. PATIENTS AND METHODS: In the period of July 2012 until August 2013 nine patients were treated with medical honey. All pa-tients had previously radiotherapy in the head and neck area. 5 patients had protracted wound healing problems after salvage surgery. The remaining 4 cases had spontaneously dehiscenced wounds at the beginning of the study. The wound healing was confirmed by measurement of the wound edges and depth and by adequate photo documentation. RESULTS: In all cases, the conventional wound care was unsuccessfully. In 8 of 9 cases, the wounds could be brought to cure by the application of medical honey over 3-8 weeks. Side effects or allergic reactions to the medical honey were not seen in any -cases. CONCLUSION: Based on our clinical experience we believe that the topical application of medical honey in non-healing or recurrent wounds in the head and neck area after radiotherapy is a reason-able and successful alternative therapy.

[Transoral robotic surgery for head and neck tumors: a series of 17 patients]. / Transorale Roboter-assistierte Chirurgie von Kopf-Hals-Tumoren: Eine Fallserie mit 17 Patienten.

BACKGROUND: Within the last years transoral robotic surgery (TORS) has gained importance in the resection of head and neck tumors, especially in North America. In contrast only few groups in Germany have studied this system so far. In respect to potential future developments in surgical robotic systems it seems reasonable to deal with this system. MATERIAL AND METHODS: 17 patients with tumors of the oropharynx, the base of tongue or the supraglottic area were treated with TORS in our clinic, between May 2011 and June 2012. In a prospective study we analyzed the exposure, visualization and resectability of these tumors using the da Vinci-system. In addition, set up and operation time, as well as costs were evaluated. RESULTS: All neoplasms of the oropharynx (n=9) and the tongue base (n=5) could be well exposed, visualized and resected. In the supraglottic area (n=3) 2 tumors could not be properly exposed and therefore resection was converted to a transoral microscopic laser approach. Resection with the cautery spatula tip or the Tm:YAG-laser fibre caused wide coagulation zones, but resulted in good hemostasis. The costs for the medical equipment and the leasing rate were 6280 € per case at our institution. CONCLUSION: Tumors of the tongue base and oropharynx could be easily visualized with help of the da Vinci-system. The resection of supraglottic tumors can be challenging, due to the arrangement of the robotic-arms and the narrow anatomic conditions. Despite its high costs, the da Vinci-system is a potentially interesting supplementation to existing surgical techniques.