[New possibilities with retroflexed functional endoscopy]. / Neue Wege der Funktionsendoskopie mit Retroflexion.

BACKGROUND: Anterograde transnasal flexible endoscopy of the pharynx, larynx, and proximal trachea without sedation has been established since the 1990s. Retroflexed endoscopic functional analysis has recently been introduced. OBJECTIVES: Adding retroflexed functional endoscopy from the oral cavity up to the duodenum to anterograde diagnostics allows the precise demonstration of how different factors interact in a complex way, e. g., in case of dysphagia or pathological reflux. MATERIALS AND METHODS: A 70-cm-long high-definition endoscope without a channel system is equipped with a 200° retroflexed view, a mm-cm scale, and a roller system. The endoscope can be lengthened, stopped, or shortened during the procedure. Standard positions, viewing directions and display details ensure that findings are comparable. Mastication, food transport and digestion are observed in the unsedated patient. RESULTS: Depending on indication and symptoms, we defined a diagnostic algorithm including three specific pathways: (1) for conditions that originate in the oral cavity, larynx or pharynx, (2) for suspected reflux disease, or for neurological or neuromuscular disorders of food transport, (3) for duodenogastric, gastroesophageal and esophagopharyngeal reflux, as well for benign or malignant tumors. CONCLUSION: The advantages of functional endoscopy have an impact not only on the medical staff and patients. Its precise and participatory approach is relevant to healthcare, enlarges the diagnostic horizon, and forms a basis for interdisciplinary collaboration.

The transnasal VideoPanendoscopy (ViP): diagnostics of the upper aerodigestive tract using an anatomically correct model from the model to the patient.

Endoscopy of the upper aerodigestive tract (UADT) develops rapidly. New endoscopes in combination with special imaging techniques allow complete examinations of the UADT in an ambulatory setting. Therefore, it is necessary to educate and train young physicians in a standardized protocol. A special anatomical training model has been designed to allow a stepwise endoscopy training course. It can be used by specialists who would like to take advantage of transnasal VideoPanendoscopy for examination of suitable candidate patients. This method offers advantages for ENT doctors, gastroenterologists as well as endoscopic surgeons.

[Position paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - current state of clinical and endoscopic diagnostics, evaluation, and therapy of swallowing disorders in children and adults]. / Positionspapier der DGHNO und der DGPP - Stand der klinischen und endoskopischen Diagnostik, Evaluation und Therapie von Schluckstörungen bei Kindern und Erwachsenen.

Position Paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - Current State of Clinical and Endoscopic Diagnostics, Evaluation, and Therapy of Swallowing Disorders in Children and AdultsSwallowing disorders are frequent. The main concern is mortality due to aspiration induced pneumonia and malnutrition. On the other hand quality of life is severely affected. The demographic trend indicates an increase of dysphagia in the future. Neurodegenerative diseases, tumors of the digestive tract and sequelae of tumor treatment in the head and neck region are the main pathologic entities.Predominantly ENT physicians and phoniatrists, are asked for diagnostics and therapy who will coordinate the interdisciplinary treatment according to the endoscopic findings.A differentiated approach in history, diagnostics, and symptom oriented treatment is necessary for the mostly complex disorders. The integration of non-medical personnel such as logopeds (speech language pathologists), physiotherapists, and occupational therapists in planning and executing an effective therapy expands and completes the patient-oriented care. Conservative treatment by these therapists is an important pillar in the treatment. Parts of the specific diagnostics can be taken over by them in close cooperation.In particular an interdisciplinary cooperation with the staff from intensive care medicine is indispensable.The diagnostic procedures of specific endoscopy as described in this position paper are part of the primary and fundamental tasks of ENT specialists and phoniatrists.Endoscopy is a medical service that is basically not delegable. Consequently substitution of the physician is precluded.

[Functional endoscopy : the physiological and pathophysiological basis of reflux disease, diagnosis and therapy]. / Funktionelle Endoskopie : Physiologische und pathophysiologische Grundlagen der Refluxerkrankung, ihre Diagnostik und Therapie.

ENT specialists and gastroenterologists are increasingly confronted with the question of how to recognize and evaluate extra-esophageal complications of reflux. Both specialities need to collaborate, since they are connected via the esophagus, and both need to know more about the speciality of their neighbor than was hitherto usual. This publication presents the observations and measurements of little-known physiological functions. This is followed by an attempt to define the border between healthy and diseased. Finally, the possible consequences of functional disorders are described. The leap from observation of function to the microcosm of biochemical links is discussed and supported using experimental work. This overview highlights the limitations of our current knowledge. The success of functional endoscopy in terms of therapeutic approaches is immense. The required therapy is finally based on a clear diagnostic concept; probatory therapy is a waste of money.

[Cinematographic study of the pathologic mechanisms of aspiration pneumonia]. / Kinematographische Untersuchung des Pathomechanismus der Aspirationspneumonie.

6% of all patients suffering from a cerebrovascular injury die from aspiration pneumonia within the first year. The high temporal resolution of high-speed cineradiography (HFK) (50 frames/sec.) allows the recording of the 0.7 sec. process of pharyngeal swallow. Five case-examples are presented (total number of cases: 95) illustrating the possibility of differentiation between three types of aspiration by means of cineradiography. These types are the so-called pre-, intra- and postdeglutitive aspiration, that is aspiration before or after triggering of the swallowing reflex. This differentiation is of great therapeutic importance. The analysis of disturbances of pharyngo-laryngeal motility and the temporal coordination allows setting up individual surgical and/or conservative programme for rehabilitation.

Design and test of a hands-free tracheostoma valve to improve the rehabilitation process after laryngectomy.

The surgical treatment of throat cancer often requires total laryngectomy. The necessary tracheostoma attracts attention, especially during speech, when one must close it manually to force air into the esophagus. To avoid this manual control, several devices have been developed. These must be placed in or around the tracheostoma and possess a valve which closes with a large air flow value. Most devices have a major drawback; coughing calls for manual adaptation, which again attracts attention. A new hands-free tracheostoma valve has been developed. The device consists of two magnetic valves, one which closes the outflow to allow speech, and one which opens to cough. Prototypes were tested in a physical model. Air flow resistance and closing pressures of the speech valve proved to be comparable to those of existing devices. Patients were enthusiastic about the new approach, even though air leakage sometimes occurred.

Experiments in surgical voice restoration using valve prostheses.

As our experience with 132 laryngectomees shows, the quality of tracheopharyngeal speech differs. Effortless tracheo-pharyngeal speech requires low flow resistance. Testing the individual factors that influence flow resistance and which are due to the prosthesis, we found that prosthesis diameter and slit length were most important. Various types of valve prosthesis differ considerably in their flow resistance. However, a low-flow resistance valve prosthesis is only partly responsible for easy phonation: Contact between the pharyngeal end of the prosthesis and surrounding tissue may influence voice quality considerably. A later paper will describe the extent to which surgery can create a low-resistance vibratile upper digestive tract.

Head and neck carcinoma models. In vivo reproduction in athymic mice and in vitro culture.

683 tumour fragments from 63 head and neck carcinoma patients were cultured in vitro. Two laryngeal carcinomas and two salivary gland carcinomas were established into permanent cell lines. Malignancy of these cultured cells was proved by cloning, by chromosomal analysis and by transplantation into athymic (nu/nu) mice. Experiments demonstrating preservation of histological, biochemical and antigenic properties in the tumour models counter the objection that tumour-specific characteristics may be lost.

[Secondary surgical voice rehabilitation]. / Die sekundäre chirurgische Stimmrehabilitation.

Surgical voice restoration is possible years after laryngectomy by using hypopharyngeal puncture and cricopharyngeal myotomy if necessary. We have developed a technique of insertion of the ESKA-Herrmann tracheostoma valve for fingerfree speech. The patient moistens and cleans the tracheostoma valve every day. The quality of fingerfree speech is the best of all known techniques.

[New aspects in the therapy of laryngeal tumors from the surgeon's viewpoint]. / Neue Aspekte in der Therapie der Larynxtumoren aus der Sicht des Chirurgen.

New techniques in tumor diagnosis allow us to improve and to refine the surgical procedure of partial laryngectomy. The first aim remains the radical tumor resection. After that we postulate a better functional surgery. Improvements were also realized using surgical voice restoration during and after laryngectomy. Technique and results are described with the use of voice prosthesis and tracheostoma valves for non-sign language speech. The treatment of laryngeal cancer today means cooperation between radiotherapy, oncology and ENT-surgery. Therefore the discussion of new developments in ENT-tumor surgery is of interest.

[Finger-free speech following total laryngectomy. Instrumentation and technic of surgical voice rehabilitation]. / Die fingerfreie Sprache nach totaler Laryngektomie. Instrumentarium und Technik der chirurgischen Stimmrehabilitation.

Surgical voice restoration during and after total laryngectomy using Blom-Singer puncture and the glottoplasty techniques provide good results. There is no doubt that the proportion of patients with a good voice is higher after surgical voice restoration than with the use of the esophageal speech or electronic speaking aids. Nevertheless there are problems due to the shunt or the necessary daily changing of the prosthesis with its risks, and failures due to the tracheostomy, the prosthesis and the pharynx. In order to reduce these surgical problems we developed new instruments, a personal surgical procedure for restoration during and after laryngectomy using this set of instruments, a new type of prosthesis and a tracheostoma valve. This technique allows the patient to speak fluently without using his hands, to breathe and to swallow without aspirating.

[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.

[Tumor associated antigens induce humoral and cellular immune response to laryngeal carcinomas (author's transl)]. / Tumorantigene induzieren humorale und zelluläre Immunantworten bei Larynxkarzinomen.

Tissue from larynx carcinomas or cultured tumor cells were incubated in the presence of patient's sera and binding of IgG antibodies was measured. Sera of 47 from 50 patients showed antibodies against their own malignomas. Furthermore 20% possessed antibodies crossreacting with isolated cultured larynx carcinoma cells. Moreover lymphocytes prepared from patient's blood lysed isolated carcinoma cells. The experiments suggest the presence of tumor associated antigens on the surface of larynx carcinoma cells.

[Experiences with the Blom-Singer prosthesis following Blom-Singer puncture and following functionally disordered neoglottis phonatria]. / Erfahrungen mit der Blom-Singer-Prothese nach Blom-Singer-Punktion und nach funktionsgestörter Neoglottis Phonatoria.

The Blom-Singer puncture is a new operative technique which can help to make the laryngectomized patient speak again even years after laryngectomy. 34 patients were treated with a modified procedure. 5 patients with a good voice gave up despite intensive medical and speech therapy. Painstaking postoperative treatment is needed to make the Blom-Singer puncture successful. Patients who had a Blom-Singer prosthesis fitted after a neoglottis procedure spoke after only brief instruction without speech therapy being necessary.

[The value of fine-needle-cytology, imprint-cytology and histology in the head-neck-region (author's transl)]. / Uber die Wertigkeit der Feinnadelzytologie, Imprintzytologie und Histologie im Kopf-Hals-Bereich.

Comparative studies about the fine-needle-cytology, imprint-cytology and histology furnished an almost complete agreement between imprint-cytology and histology. Suspected tumor findings by way of fine-needle-biopsy deserve the same place as similar histological examinations. Negative cytological results have to be critically evaluated. Fine-needle-cytology presents a quick and not too painful procedure that is both relatively free of complications and repeatable examination.

Establishment of carcinoma cell lines from larynx and submandibular gland.

For many techniques in the oncology of head and neck tumors large amounts of pure tumor cells are required. Although larynx and salivary gland tumors are common in man, no report exists on isolation and purification of tumor cells of which malignancy was proved. The present paper describes in vitro cultivation of living human malignant tumor cells from a larynx and a submandibular gland carcinoma. Carcinoma cells were freed from all non-tumor cells and cloned thus indicating that cultures contained only a single cell type. Transplantation of grown cells s.c. into athymic (nu/nu) mice induced rapidly growing tumors of which malignancy was demonstrated by histology.

[Monoclonal antibody UW 21/123: clinical use and diagnostic specificity in head and neck cancers]. / Der monoklonale Antikörper UW 21/123: Klinische Anwendung und diagnostische Spezifität bei Kopf- und Halskarzinomen.

In addition to the originally described monoclonal antibody (MAB) against laryngeal carcinoma cells (Arch. Otorhinolaryngol. 233 (1981) 161) a new MAB was induced by means of somatic cell hybridisation techniques. The MAB UW 21/123 enables recognition of a group of squamous cell carcinomas of the head and neck. An in-vitro assay was designed allowing clinical diagnosis of malignancy in 18% out of 211 tumour patients.

[Fine-needle biopsy in tumor diagnosis of the head and neck region. A method for general practice]. / Die Feinnadelpunktion zur Tumordiagnostik im Kopf-Halsbereich. Eine Methode für die Praxis.

During the last 4 years over 1500 thin-needle aspiration biopsies from tumors in the head and neck region were carried out in the University-ORL-Clinic of Würzburg. 306 cytological results were compared with the histological diagnoses. None of the benign tumors was classified cytologically as malignant (false positive = 0%). 84% of the malignancies were attached to the groups III, IV or V according to the so called Pap.-staging. The rest could not be detected by this method because of technical mistakes as well as accidental false punctions. Some types of tumors could be classified histogenetically in high percentage of cases, especially the pleomorphic adenoma of the glandula parotis and carcinoma metastases.