Management and outcome of vagus nerve stimulator implantation: experience of an otolaryngeal/neuropediatric cooperation.

OBJECTIVE: Vagus nerve stimulator (VNS) implantation is an established therapy for pharmacoresistant epilepsy that is not amenable to curative epilepsy surgery. Historically, VNS implantation has been performed by neurosurgeons, but otolaryngologist involvement is increasingly common. In this retrospective study, we aimed to evaluate the efficacy and safety of VNS implantation in children and adolescents from the otolaryngologists' perspective. METHODS: This study included children and adolescents who had undergone VNS implantation at the study center between 2014 and 2018. Patient files were analyzed with regards to the durations of device implantation and hospitalization, postoperative complications, and clinical outcome, including seizure frequency, clinical global impression of improvement (CGI-I) score, and quality of life (QoL). RESULTS: A total of 73 children underwent VNS surgery. The median age at implantation was 9.3 ± 4.6 years, and median epilepsy duration before VNS surgery was 6 ± 4 years. Lennox-Gastaut syndrome was the most common syndrome diagnosis (62.3%), and structural abnormalities (49.3%) the most frequent etiology. Operation times ranged from 30 to 200 min, and median postoperative hospitalization length was 2 ± 0.9 days. No complications occurred, except for four revisions and two explantations due to local infections (2.7%). Among our patients, 76.7% were responders (≥ 50% reduction in seizure frequency), 72.1% showed improved CGI-I scores, and 18.6-60.5% exhibited considerable improvements in the QoL categories energy, emotional health, and cognitive functions. CONCLUSION: Our results indicate that VNS implantation is a highly effective and safe treatment option for children and adolescents with AED-refractory epilepsies who are not candidates for curative epilepsy surgery.

[Navigation-assisted sonography for soft tissues in the head and neck region]. / Navigationsunterstützte Weichteilsonographie für den Kopf-Hals-Bereich.

BACKGROUND: In soft tissue surgery of the head and neck region tissue shifts limit the usefulness of conventional CT/MRI-based navigation procedures. Furthermore, changes caused by invasive measures cannot be visualized. METHODS: A novel navigation device for sonography of soft tissues was developed. This consists of a navigated ultrasound scanner, a navigated surgical instrument, and a personal computer with custom-made software. Its use makes an additional visualization by means of CT or MRI dispensable. RESULTS: The system deviation (three-dimensional error) of this newly developed prototype was less than 1 mm. The practical application in a model setup showed good handling properties of the system. Orientation and approach of the surgical instrument to the sonographically visualized target structure were rapid and accurate. CONCLUSION: This new navigation system does not require additional CT or MRI images. The navigated ultrasound probe shows tissue changes in real time. This navigation system is especially suitable for invasive procedures in soft tissues.

Pre-treatment haemoglobin level predicts response and survival after TPF induction polychemotherapy in advanced head and neck cancer patients.

OBJECTIVE: To investigate the prognostic value of the pre-treatment haemoglobin level in patients with advanced squamous cell head and neck cancer treated with induction polychemotherapy. DESIGN: Seventy-two patients with advanced squamous cell head and neck cancer received primary combination chemotherapy consisting of docetaxel 75 mg/m(2) on day 1, cisplatin 100 mg/m(2) on day 1, and 5-fluorouracil (5-FU) 1000 mg/m(2)/day on days 1-4 (total dose 4000 mg/m(2)), repeated on days 1, 22 and 43 followed by chemoradiation. The data collected included pre-treatment haemoglobin, response to treatment, disease-free and overall survival. RESULTS: The pre-treatment haemoglobin level was found to be a significant predictor of response to induction chemotherapy (P = 0.01) and an independent predictor of overall survival [hazard ratio (HR) 0.77, 95% confidence interval (CI) 0.58-1.03, P = 0.0001] and disease free survival (HR 2.09, 95% CI 1.41-3.09, P = 0.0001). Furthermore N-stage was found to be a significant prognostic factor of overall survival (HR 9.24, 95% CI 6.90-21.34, P = 0.005). The Eastern Cooperative Oncology Group performance status scale was also found to be significant for disease free survival (HR 7.66, 95% CI 2.61-22.46, P = 0.003). CONCLUSION: In patients with advanced squamous cell head and neck cancer, the haemoglobin level prior to induction chemotherapy is significantly related to outcome including response and survival.

Vestibular nuclear complex in the guinea pig: a cytoarchitectonic study and map in three planes.

Cytoarchitectonic and fiberarchitectonic criteria were used in the preparation of a detailed map illustrating the vestibular nuclear complex of the guinea pig. The brainstems used for this study were serially cut at 16 micron in the transverse, the sagittal, or the horizontal plane. The sections were studied after being stained alternately with a combined cell and fiber staining method and a Nissl stain. The basic cytoarchitectonic features of the four main vestibular nuclei, their extent, as well as their relationship to the surrounding structures are described. Additionally, the location, topographical features, and the cytoarchitecture of the small groups (f,g,l,x,y,z) associated with the vestibular nuclei are reported. Group f is especially well developed and easily distinguishable in the guinea pig. Furthermore, a hitherto undescribed cell cluster found dorsal to the dorsal border of the superior vestibular nucleus is presented. The results and especially the differences from the descriptions of other species are discussed.

Brainstem projection of the vestibular nerve in the guinea pig: an HRP (horseradish peroxidase) and WGA-HRP (wheat germ agglutinin-HRP) study.

We explored the course and termination of primary vestibular afferent fibers within the brainstem of the guinea pig by means of anterograde axonal transport of horseradish peroxidase (HRP) and wheat germ agglutinin-conjugated horseradish peroxidase (WGA-HRP). Primary vestibular afferent fibers distribute within the entire vestibular nuclear complex, with the exception of the dorsal part of the lateral vestibular nucleus. The superior vestibular nucleus is characterized by the concentration of terminals within its central part. Although terminal labeling is weaker within the periphery, no area completely lacks primary input. The lateral vestibular nucleus can be divided into a ventral and a dorsal part; within the ventral part small and giant cells receive primary afferent fibers, whereas no significant terminal labeling occurs in the dorsal part. The medial vestibular nucleus shows the most uniform labeling, although the lateral part of its rostral third has a few more terminals than the medial half. Primary projection to the descending vestibular nucleus is widespread, although in its rostrodorsal part it is less impressive. Of the small cell groups commonly associated with the vestibular nuclear complex, only group y receives abundant primary input. Whereas group z completely lacks labeled fibers as well as terminals, single primary axons can be observed passing groups x and f. However, no terminals can be found within the borders of these two cell groups. Scanty projections can be detected within the prepositus hypoglossi nucleus, as well as within the external cuneate nucleus, the cochlear nucleus, the abducent nucleus, and parts of the reticular formation.

Projection of primary vestibular afferent fibres to the cochlear nucleus in the guinea pig.

After tracing the superior branch of the vestibular nerve and the macula sacculi by means of the neuronal tracers horseradish peroxidase (HRP) and wheat germ conjugated horseradish peroxidase (WGA-HRP), a conspicuous fibre bundle running into the cochlear nucleus could be observed. The HRP-labeled axons travel caudally through the descending vestibular nucleus, enter the cochlear nucleus at a level caudal to subgroup y and terminate at cells situated between the dorsal and posteroventral cochlear nucleus. Considering recent electrophysiological studies, it is reasonable to imply that these fibres are involved with the transduction of acoustic stimuli.

The origin of the vestibulo-cochlear projection in the guinea pig.

Previous tracer studies have revealed the sacculus to be connected to the vestibular and cochlear nuclei in the guinea pig. Due to its own innervation pattern, an anterior and posterior part of the sacculus can be distinguished. The present study investigated whether the two parts differ concerning their fiber contribution to the vestibulo-cochlear projection. After tracing the nerve of the posterior sacculus with horseradish peroxidase (HRP), the vestibulo-cochlear fibers were clearly recognizeable and showed distinct terminal labeling within the cochlear nuclei. In contrast, no terminals were identified in the cochlear nuclei after tracing the anterior sacculus. These results may further substantiate the guinea pig vestibulo-cochlear projection as a central pathway for saccular acoustic sensation.

Carcinomas unresponsive to either cisplatinum or anti-EGFR therapy can be growth inhibited by combination therapy of both agents.

BACKGROUND: Previously we demonstrated that the antitumor efficacy of monoclonal antibodies against the EGFR (epidermal growth factor receptor) of human tumor xenografts mainly depends on the EGFR content of tumors rather than on the tumors' entity. In this study we wanted to elucidate whether the described cumulative effect of cisplatin and Anti-EGFR therapy also depends on the EGFR expression. MATERIALS AND METHODS: Xenotransplanted carcinomas with different EGFR levels were treated with monoclonal antibodies against the EGFR (EMD 72000 and EMD 55900), cisplatinum and a combination of both. RESULTS: Each monoclonal antibody alone led to an EGFR-dependent significant tumor growth reduction. Cisplatinum alone had no growth inhibitory effects on tumors with high content in contrast to those with low EGFR content. The combination of antibodies with cisplatinum resulted in an EGFR-independent tumor growth inhibition which was stronger than observed in the case of monotherapy. DISCUSSION: The obtained results may address upcoming phase I/II trials to use Anti-EGFR/Cisplatinum therapy regardless of the EGFR content of tumors.

The sternocleidomastoid flap--its indications and limitations.

HYPOTHESIS: The sternocleidomastoid (SCM) flap seems to be a practicable but underestimated flap for reconstructive and plastic surgery of the head and neck. OBJECTIVES: To determine in which situations the SCM flap may represent a reliable alternative to other flaps used in head and neck surgery. STUDY DESIGN: Meta-analysis of the complete literature on the SCM flap. SETTING: All literature found dealing with the SCM flap was reviewed, with special emphasis placed on the indications and success rates reported. The data presented are compared with our own morphologic findings and their putative clinical implications. RESULTS: Four types of SCM flap have been described: the muscle flap, the myocutaneous flap, the myoperiosteal flap, and the myosseus or osteomuscular flap. The SCM flap was either superiorly or inferiorly based. The SCM muscle flap was used in a total of 72 patients with only 1 major complication and 7 minor complications. The complication rate, therefore, is 11%. The applications of the muscle flap involved prevention of Frey's syndrome, closure of orocutaneous fistulae and soft tissue deficiencies, closure of pharyngocutaneous and cervical esophageal fistulae, and reconstruction of the tongue. Furthermore, Conley reported on the use of the SCM muscle flap in a group of 30 patients to reanimate the face, reconstruct oral cavity defects, protect the carotid and innominate artery, and even to aid shoulder elevation after poliomyelitis. The SCM myocutaneous flap seems to be the most common application, with a total of 138 patients. All in all, a total of 29 complications (21%) was reported, with partial skin necrosis by far the most frequent. Total failure of the flap has been described in 10 patients (7%). The SCM myocutaneous flap was used for closure of defects of the mouth as well as oro-, pharyngo-, and tracheocutaneous fistulae, facial reconstruction, reconstruction of mastoid defects, and reconstruction of the laryngotracheal complex in children. The SCM myosseus or osteomuscular flap was reported in 23 patients. Flap necrosis is reported in 1 case (4%). The SCM osteomuscular flap was used to reconstruct defects of the lower jaw in all patients. The SCM myoperiosteal flap was used in a total of 49 patients. The complication rate reported is 6% (3 cases). The myoperiosteal flap was used for reconstruction of the laryngotracheal complex in adults and for esophagopharyngeal reconstruction and fistula repair. CONCLUSIONS: The data presented in previous literature is well correlated with our own morphologic findings. In comparison of the different techniques applied with the assumptions drawn on the basis of our own anatomic findings, it becomes evident that the SCM flap is only a useful tool in limited indications and under certain precautions.

Intraoperative electromyography for identification of the trapezius muscle innervation: clinical proof of a new anatomical concept.

OBJECTIVE/HYPOTHESIS: There is still considerable controversy among surgeons on trapezius muscle innervation. In addition, the rate of unexpected postoperative trapezius pareses is unacceptably high. Recent anatomical findings might answer most of the questions. The objective of the present study was to clinically prove the recent anatomical findings, especially the concept of the innervation of the descending part of the trapezius muscle. STUDY DESIGN: Intraoperative electromyography of the spinal accessory nerve and its branches in the posterior triangle of the neck. SETTING: Intraoperative electromyography was performed during 17 modified radical neck dissections on 14 patients of both sexes ranging in age from 44 to 68 years (mean age, 56 y). Potentials were registered through pairs of needle electrodes placed in each of the three parts of the trapezius muscle. Intraoperatively, the spinal accessory nerve and its fine cranial branch passing toward the descending part of the muscle were identified and stimulated in the posterior triangle of the neck.RESULTS Stimulation of the fine cranial branch of the spinal accessory nerve led to a clearly visible and recordable contraction in the descending part of the trapezius muscle in all patients. Stimulation of the main trunk of the spinal accessory nerve in the posterior triangle of the neck distal to the above-mentioned branching led to a clearly visible and recordable contraction in the transverse and ascending parts of the muscle. CONCLUSIONS: The results strongly support recent anatomical findings showing that, functionally, the most important descending part of the trapezius muscle is innervated by a fine single branch arising from the spinal accessory nerve in the posterior triangle of the neck. This may help to prevent more patients undergoing modified radical neck dissections from shoulder-arm syndrome.

CT and MR imaging of acquired abnormalities of the inner ear and cerebellopontine angle.

INTRODUCTION: Several entities of acquired lesions may affect the inner ear and cerebellopontine angle. The imaging of these lesions depends on the clinical history, and should be adapted to the lesion searched for and suspected by the otolaryngologist. In this paper, the modality of CT and MR imaging which is suited to delineate the acquired lesions of this region will be presented. MATERIALS AND METHODS: CT and/or MR imaging of the inner ear and cerebellopontine angle was performed in all cases in which an acquired lesion of this region was suspected by the otolaryngologist. CT was performed in the axial and coronal plane with the use of a high-resolution bone-window-level-setting. MRI was performed in the axial plane using high-resolution 3D T2-weighted fast spin echo sequences and 3D T1-weighted gradient echo sequences before and after the i.v. application of gadopentate dimeglumine. The obtained images were evaluated for the depiction of the acquired lesions. RESULTS: CT best depicted osseous lesions such as traumatic affections or lesions leading to ossification of the inner ear. Tumorous lesions were delineated in those cases in which they yielded to bony changes. Inflammatory or tumorous lesions not yielding to bony changes or intralabyrintine calicifications were not depicted. MRI delineated very well all lesions leading to soft tissue changes, and moderately depicted traumatic changes yielding to less severe fractures affecting the investigated region. CONCLUSION: CT and MR imaging are suited differently to delineate the acquired lesions of the inner ear and cerebellopontine angle. CT is excellently suited to depict osseous lesions, while MRI is excellently suited to delineate lesions affecting the soft tissue structures. These two imaging modalities should be used depending on the clinical question, and are supposed to be complementary methods.

Clinical application of magnetic resonance imaging in 30 cochlear implant patients.

OBJECTIVE: The goal of this investigation was to provide evidence that magnetic resonance imaging (MRI) can be performed safely and effectively on cochlear implant patients who require diagnosis of additional diseases. STUDY DESIGN: A retrospective study was performed over 5 years. In a total of 300 patients with cochlear implants at the authors' center, MRI was performed whenever it was medically indicated. SETTING: All patients underwent scanning in a Philips Gyroscan T10-NT MRI machine, using commercially available Powertrac 3000 software. PATIENTS: All patients with cochlear implants for whom MRI was indicated (n = 30) were included in this study. They had a wide variety of conditions necessitating MRI, including cervical discus prolapse, hypophyseal adenoma, epipharynx carcinoma, knee degeneration, parotid tumor, and preoperative evaluation for reimplantation and bilateral implantation. RESULTS: No adverse effects from the MRI were reported by any of the patients. The cochlear implants all retained their function. All images were of diagnostic value. Because of the MRI, the patients did not need to undergo additional, more invasive and expensive diagnostic procedures. Examples of MRI images from 5 patients are shown. CONCLUSIONS: MRI on cochlear implant patients, using the Med El Combi 40 and Nucleus mini 22 series at 1 Tesla, can be a safe procedure. Removal of any magnet is not necessary.

Variant petrotympanic fissure as possible cause of an otologic complication during TMJ arthroscopy. A case report.

In this reported case, a variant petrotympanic fissure--opening at the height of the orifice of the Eustachian tube into the hypotympanon--was identified by high resolution computed tomography (CT) as the possible cause of a tympanic membrane perforation. Inner ear function was preserved by an otosclerotic stapes which prevented destruction of the labyrinth. The perforation was closed by a myringoplasty and was to be followed by a stapedectomy after six months to restore normal hearing. Surgeons performing temporomandibular joint arthroscopy should be aware that in a small percentage of patients a variant anatomy of the tympanic plate exists and, therefore, great care must be exercised in the manipulation of instruments near this structure. A preoperative high resolution CT with thin slices of the temporal bone might allow identification of these high risk patients.

Follow up of cochlear implanted handicapped children.

OBJECTIVE: To document progress and benefit of multi-handicapped children using cochlear implants. DESIGN: The evaluation of auditory responses to speech (EARS) test battery was performed on the children in this study at regular intervals following implantation. All children went through individually tailored intensive audiological rehabilitation programs following cochlear implantation. RESULTS: Individual results from ten multi-handicapped children receiving cochlear implants are presented in this paper. The majority of children in this study are successful implant users. Whenever possible, test scores are included as well as subjective case reports. CONCLUSION: Providing multi-handicapped children with cochlear implants can result in substantial benefit for both the child and parents. Multi-handicapped children are not contraindicated for cochlear implantation, although not all are considered to be good candidates.

Central projections from singular parts of the vestibular labyrinth in the guinea pig.

Primary afferent projections from singular parts of the vestibular labyrinth were studied in the guinea pig. The posterior ampullary nerve, the common trunk of the anterior and lateral ampullary nerves, as well as fibers innervating the macula sacculi or the macula utriculi were traced with crystals of horseradish peroxidase (HRP) lyophilisate. Posterior, as well as anterior and lateral ampullary fibers were found to project extensively to the superior vestibular nucleus, but also reached the other main vestibular nuclei. Saccular fibers projected mainly to the lateral parts of the lateral vestibular nucleus and to the adjoining descending and superior vestibular nuclei as well as to group y. Modest projections could be followed to the medial vestibular nucleus. Furthermore, a distinct saccular projection to the cochlear nuclei was evident. Utricular projections reached the four main vestibular nuclei with a denser accumulation of fibers within ventral parts of the lateral, descending and superior vestibular nuclei.

Speech discrimination scores of postlingually deaf adults implanted with the Combi 40 cochlear implant.

The aim of the study was to assess the speech discrimination ability of postlingually deaf adults implanted with the Combi 40 cochlear implant and to compare the results with the postoperative data published for other devices. The postoperative open and closed set speech perception performance of 21 consecutive patients was tested using a standardized test battery comprising a number, monosyllable, sentence, consonant and vowel discrimination test as well as a rhyme test in the sound only condition. Mean values achieved for each test 1, 6 and 12 months after "switch on" were evaluated. The results demonstrate that all patients have a substantial benefit from their implant and show a continuous improvement in their speech perception abilities with increased device experience. The mean percentages of correct answers after 12 months were 93.4 for numbers, 44.6 for monosyllables, 78.5 for sentences, 67.6 for the rhyme test, 59.8 for vowel, and 67.3 for consonant discrimination. Preoperatively, the mean discrimination score for monosyllables was 0%. The speech discrimination scores of our patients were similar or higher than described for similar patient groups implanted with other devices. The high stimulation rate of the implant system using the continuous interleaved speech processing strategy as well as a deep atraumatic electrode insertion into the apicalmost regions of the scala tympani may be the reason for good performance.

Speech perception performance in prelingually deaf children with cochlear implants.

The goals of this study were to report on mean values of speech perception performance in prelingually deaf children implanted with a Combi 40/40 + cochlear implant. A total of 31 patients were included in the study. The time span ranged over 3 years, during which time the Evaluation of Auditory Responses to Speech (EARS) test battery was used with the children. The EARS battery contains four measures of closed-set speech perception and three open-set tests. The mean test results exhibited steady improvement on all parts of the EARS test battery, even up to 3 years post-implantation. The preoperative scores for the Listening Progress Profile (LiP) were 4%, rising to 93% at 36 months post-implantation. Results for the open-set testing measures were most encouraging, with some children reaching fairly high levels of speech perception, receiving scores as high as 100%, by the 36-month evaluation. The congenitally and prelingually deaf children in our study showed continuous improvement in both closed and open set speech perception following cochlear implantation, although variability in individual performance among the children was noted.

Fixation of the electrode array with bone paté in cochlear implant surgery.

The aims of this study are to report on our experiences using a bone paté (a mixture of bone dust and fibrin glue) fixation technique of the Combi 40/Combi 40+ electrode array during cochlear implant surgery. A retrospective study involving 57 patients implanted with Combi 40/Combi 40+ cochlear implants over 31 months fixated with bone paté was performed, utilizing our electrical fitting data as well as re-operation and X-ray findings. We found no signs of electrode retraction in any of the 57 patients. Electrical fitting data showed no reduction in the number of active channels between the first and last times patients were evaluated (a period of 4-31 months). Furthermore, a comparison of X-rays performed within the first week following cochlear implant surgery and again 7-27 months later showed no signs of electrode retraction in 10 patients. Three patients who required re-operations after implantation allowed us the opportunity to examine the effectiveness of the bone paté fixation and revealed new bone growth with the electrode fixed in place. Histological examinations of the newly built bone showed laminar and compact bone structures. The use of bone paté was thus found to be a suitable method of electrode fixation in cochlear implant surgery. Compared with other fixation methods, it is inexpensive and uses no foreign materials.

Auditory fractal random signals: experimental data and clinical application.

In the mammalian primary cochlear afferents, fractals in the postsynaptic bursting behaviour triggered by a constant perisynaptic release of glutamatergic transmitter agonists have been demonstrated. In order to test the validity of fractally coded auditory signal transmission in man, frequency, intensity and temporal resolution tests were performed in cochlear implanted patients. All patients clearly recognized the fractally coded signals transmitted to the cochlear implants. These first results demonstrate evidence for fractally coded auditory signal transmission in man.