[Skull base surgery in the German DRG system-New categorization of important procedures]. / Die Schädelbasischirurgie im deutschen DRG-System ­ Neue Zuordnung wichtiger Prozeduren.

Surgery of the skull base includes interventions between the nose or paranasal sinuses (anterior skull base) or ear/temporal bone (lateral skull base) and the intracranial space. As interventions at the anterior skull base almost exclusively involve complex pathologies in a demanding anatomical region, in many cases two experienced surgeons from different disciplines are required who should be experienced in operating together. The technical and time requirements are also considerable in many cases; however, for many procedures there are no specific skull base operational and procedural keys (OPS) codes that take the considerable personnel and structural effort into account. A change in the diagnosis-related groups (DRG) system, implemented since the beginning of 2023, now adjusts the remuneration of the abovementioned effort for malignant pathologies of the anterior and lateral skull base. The reallocation of procedures 5­015.0/1/3/4 and 5­016.0/2/4/6 results in a significant upgrade of anterior and lateral skull base surgery. Since the beginning of 2023 skull base surgery will no longer be charged under DRG D25C with a (former) relative weight of 1.893, but with DRG D25B with a current relative weight of 3.753 when a code of the aforementioned groups is used. Nevertheless, further adjustments are necessary, for example, in the available reconstructive steps in order to provide the Institute for the Remuneration System in Hospitals (InEK) with the most differentiated data possible on the procedural effort of the intervention and to achieve a more balanced distribution of the reimbursements of skull base surgery in the long term.

[Accreditation and certification of skull base centres in Germany by the German Society for Skull Base Surgery (Gesellschaft für Schädelbasischirurgie, GSB). German version]. / Akkreditieren und Zertifizieren von Schädelbasiszentren in Deutschland durch die Gesellschaft für Schädelbasischirurgie (GSB).

The German Society for Skull Base Surgery (Gesellschaft für Schädelbasischirurgie, GSB) has developed a protocol for the certification of GSB skull base centres. The development of such a protocol has led to numerous open and sometimes controversial discussions among the GSB members. The various critical discussion points will be reviewed and the ensuing results, which will then be included in the accreditation protocol, presented. The current GSB accreditation protocol will be presented and explained in an international comparison.

Accreditation and certification of Skull Base Centres in Germany by the Society for Skull Base Surgery (Gesellschaft für Schädelbasischirurgie, GSB).

The German Society for Skull Base Surgery (Gesellschaft für Schädelbasischirurgie, GSB) has developed a protocol for the certification of GSB skull base centres. The development of such a protocol has led to numerous open and sometimes controversial discussions among the GSB members. The various critical discussion points will be reviewed and the ensuing results, which will then be included in the accreditation protocol, presented. The current GSB accreditation protocol will be presented and explained in an international comparison.

[Social reimbursement-the Spanish-German ENT Society's (SDGHNO) Latin America project]. / Soziale Rückvergütung ­ das Projekt "Lateinamerika" der Spanisch-Deutschen HNO-Gesellschaft (SDGHNO).

Nowadays, social projects are usually oriented in such a way that after a given period of time, they can either support themselves independently or even allow a pecuniary reimbursement. In the latter case, experts speak of a profit-oriented reimbursement. On the other hand, there is so-called social reimbursement, which in contrast to the abovementioned form is not profit oriented, but, for example, considers its task fulfilled by the fact of successful knowledge transfer. The Spanish-German Society for ENT Medicine and Head and Neck Surgery (SDGHNO) launched the Latin America project in 2001 under the patronage of the then President Prof. Dr. Wolfgang Draf (Fulda). The goal of the SDGHNO was and is to create a professional as well as cultural platform for Spanish- and German-speaking ENT doctors. This platform can and should be used for professional purposes, e.g., for knowledge transfer. Since the beginning of its existence, the Latin America project has thus brought numerous scientific events into being and created specific contacts which have lasted until today or have even been continued and further developed. Particularly successful examples are Chile, Colombia, and Peru. This is a vivid example of social reimbursement, because the participating German-speaking members/speakers carried out their tasks on an entirely voluntary basis. Thus, the SDGHNO did not bear any travel, catering, or accommodation costs. The activities of the SDGHNO within the framework of the Latin America project are explained.

A chemically modified antibody mediates complete eradication of tumours by selective disruption of tumour blood vessels.

BACKGROUND: The possibility of eradicating cancer by selective destruction of tumour blood vessels may represent an attractive therapeutic avenue, but most pharmaceutical agents investigated so far did not achieve complete cures and are not completely specific. Antibody conjugates now allow us to evaluate the impact of selective vascular shutdown on tumour viability and to study mechanisms of action. METHODS: We synthesised a novel porphyrin-based photosensitiser suitable for conjugation to antibodies and assessed anticancer properties of its conjugate with L19, a clinical-stage human monoclonal antibody specific to the alternatively spliced EDB domain of fibronectin, a marker of tumour angiogenesis. RESULTS: Here we show in two mouse model of cancer (F9 and A431) that L19 is capable of highly selective in vivo localisation around tumour blood vessels and that its conjugate with a photosensitiser allows selective disruption of tumour vasculature upon irradiation, leading to complete and long-lasting cancer eradication. Furthermore, depletion experiments revealed that natural killer cells are essential for the induction of long-lasting complete responses. CONCLUSIONS: These results reinforce the concept that vascular shutdown can induce a curative avalanche of tumour cell death. Immuno-photodynamic therapy may be particularly indicated for squamous cell carcinoma of the skin, which we show to be strongly positive for markers of angiogenesis.

[Acoustic neuroma (vestibular schwannoma) therapy from an oto-rhino-laryngological perspective]. / Therapie des Akustikusneurinoms (Vestibularisschwannoms) aus der Sicht der HNO-Heilkunde.

Acoustic neuroma/vestibular schwannoma treatment has changed considerably since the 1990s, when surgical treatment was recommended in all cases of schwannoma, whereas nowadays a more differentiated approach is taken. The three classical approaches (translabyrinthine, transtemporal, and suboccipital) still have their surgical value; however, greater importance is apportioned to radiotherapy (radiosurgery, gamma- and cyber-knife). Magnetic resonance imaging in particular has changed diagnostics and how tumor growth is followed. Electrophysiological monitoring of facial and auditory nerves has helped lower postoperative morbidity. New issues have been raised regarding quality of life. Neuropsychological investigations for cognitive and mnestic performance following procedures in the cerebellopontine angle have highlighted problem areas receiving hitherto little attention. Finally, the therapy of this benign lesion should be planned individually, taking the patient's age as well as their professional and personal status into consideration.

[Multifocal manifestation of Rosai-Dorfman disease. A rare case of purely extranodal sinus histiocytosis in the elderly]. / Multifokale Manifestation einer Rosai-Dorfman-Erkrankung. Seltene, rein extranodale Sinushistiozytose im Erwachsenenalter.

Rosai-Dorfman disease belongs to the group of childhood histiocytoses and was initially described as sinus histiocytosis with massive lymphadenopathy. Its rare purely extranodal manifestation is primarily found in the head and neck region. An atypical primary manifestation in an elderly patient with multifocal extranodal disease is described, and this pathological entity is reviewed. Specific difficulties concerning differential diagnostic aspects as well as individually appropriate treatment strategies are discussed.

[Traumatic optic neuropathy: a review of the literature in the light of personal experiences]. / Die traumatische Optikusneuropathie: Aktuelle Literaturübersicht im Spiegel eigener Erfahrungen.

BACKGROUND: Therapy of traumatic optic neuropathy (TON) is still discussed controversially. Studies of medical treatment and surgical decompression of the nerve could not find any correlation between therapy and result. Today's knowledge of the treatment in TON is to be analyzed by the latest results in the literature, supplemented by personal experiences with our own patients, who underwent a combination of corticosteroids and surgical decompression. METHODS: The study group consisted of 9 patients at the age of 13-58 years. 8 patients suffered from a cranial trauma, 1 patient had sinus surgery, which resulted in an indirect damage of the optic nerve. Pretherapeutically, 5 patients had residual vision, 4 patients were blind. A fracture line through the optic canal in the CT-scan was seen in 6 cases. Decompression was performed within 24 hours in 3 cases; in the worst 3 cases it took up to 8 days. In 8 patients the intervention was performed via an endonasal, microscopic-endoscopic approach, once it was done transfacially. Simultaneously, high-dose corticosteroids were administered. RESULTS: All patients with a residual vision before therapy showed an improvement of their visual acuity: In the best case visual acuity changed from perception of light to 0.8. All patients with posttraumatic blindness remained blind after therapy. CONCLUSION: A surgical decompression may be considered in patients with residual vision. Referring to the latest data in the literature endonasal, microscopic-endoscopic decompression is then to be combined with simultaneous application of high-dose corticosteroids. In our opinion, a mere wait-and-see strategy completely without any treatment can hardly be recommended.

[Acute complications during middle ear surgery: part 1: Problems during tympanoplasty--what to do?]. / Akute Komplikationen in der Mittelohrchirurgie: Teil 1: Probleme während der Tympanoplastik--was tun?

Due to the unusual anatomical situation in the middle ear, there are a variety of possible complications that may occur during tympanoplasty. Dislocation of the ossicular chain with and without opening of the labyrinth, injuries to the facial nerve and hemorrhage from large arteries and veins may occur. Adequate management of these complications is necessary in order to avoid further damage for the patient. The first question in case of an acute complication is always whether it is possible to stop the operation. It is also important to determine the time to react, e.g. if an injury of the facial nerve is assumed, when a revision needs to be performed. It also should be considered to refer the patient to a colleague who is not as emotionally involved in the case as the primary surgeon.

[Acute complications during middle ear surgery: part 2: Accidents in classical stapes surgery and their solutions]. / Akute Komplikationen in der Mittelohrchirurgie: Teil 2: Missgeschicke in der klassischen Stapeschirurgie und ihre Behebung.

Stapes surgery is remarkably different from regular middle ear surgery. The inner ear space has to be opened and the risk of postoperative deterioration of hearing and deafness is much higher. Peculiarities involve submerged parts of the foot plate into the vestibulum, the overhanging facial nerve with or without bony covering, bleeding from the mucosa, and problems involving the chorda tympani. Labyrinthine reactions during or post surgery are common. Important is the question of whether or when the piston should be removed. Rare cases such as a gusher with a wide connection between perilymph and CSF space are a major challenge in stapes surgery.

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.

Angiography and cerebral perfusion scintigraphy in balloon test occlusion of carotid artery in head and neck tumors.

PURPOSE: Surgery of head and neck tumors and other tumors involving the carotid artery may demand complete sacrifice of the carotid as part of the necessary tumor therapy. Sacrifice of the carotid may result in permanent brain perfusion damage. This uncorrectable procedure has to be tested beforehand in order to exclude this possibility. MATERIALS AND METHODS: In order to predict this possible unstable hemodynamic brain perfusion damage, we evaluated 12 patients with head neck tumors prior to possible sacrifice of the carotid. The following tests were applied: angiography of the neck vessels, balloon test occlusion (BTO) of the carotid lasting 10 minutes combined with perfusion reserve testing using 1000 mg acetazolamide i. v. All patients received brain perfusion scintigraphy SPECT with Tc-99 m HMPAO injected during BTO. RESULTS: All patient data were evaluated for clinical neurological defects under BTO. Perfusion of the great vessels was evaluated semiquantitatively for angiography (filling delay of the ophthalmic artery) and perfusion SPECT. None of the patients suffered from neurological defects. 9 /12 patients showed mild to severe perfusion defects. 9 /12 patients showed filling delays of more than 1 second. Both tests showed a very good correlation (p = 0.005). Only 2 /12 cases were discrepant in one degree. All severe defects were congruent in both tests. CONCLUSION: None of the patients with severe defects underwent sacrifice of the carotid. Both tests resulted in increased security regarding the prediction of possible brain perfusion damage. The combination of angiography and brain scintigraphy is logistically easy and has a high value of prediction.

[Results in otosurgically treated patients with acoustic neuroma. Part 2: Hearing results after middle fossa approach]. / Ergebnisse otochirurgisch operierter Patienten mit Akustikusneurinom. Teil 2: Hörergebnisse nach transtemporaler Resektion.

BACKGROUND: The surgical therapy of acoustic neuromas has been seen critically lately. Alternative methods like the gamma-knife treatment open a wide field of discussion. PATIENTS: The results of 392 patients are presented operated on via a middle fossa approach between 1989 and 2004. RESULTS: Hearing preservation according to the 50:50 rule (hearing loss less than 50 dB in pure tone audiogram 500-1000-2000 Hz, speech discrimination>50%) was possible in 59.7% of patients. A hearing impression up to 90 dB was recognized in 83.1%, 16.9% of cases were deaf. There was no difference between tumors confined to the inner ear canal and tumors extending into the cerebello pontine angle. There was also no difference between tumors up to a volume of 100 mm3 and tumors between 100 mm3 and 500 mm3. CONCLUSION: Acoustic neuroma confined to the internal meatus or with little extend into the cerebello pontine angle (i. e. no contact to structures of the brain stem or vessels of the posterior fossa) are feasible for resection via the middle fossa approach. The possibility of hearing preservation and low morbidity makes it the treatment of choice for this group of tumors.

[Results in otosurgically treated patients with acoustic neuroma. Part 1: Facial nerve function after translabyrinthine and middle fossa resection]. / Ergebnisse otochirurgisch operierter Patienten mit Akustikusneurinom. Fazialisfunktion nach translabyrinthärer und transtemporaler resektion.

BACKGROUND: Regardless of all efforts to preserve a residual hearing, facial nerve function is still the primary issue for patients with acoustic neuromas. Since alternative methods like the gamma-knife treatment are of increasing importance, results after surgery have to be compared and discussed critically. PATIENTS: The results of 538 patients operated at the Dept. of Otolaryngology, Head and Neck Surgery, University of Wuerzburg between 1989 and 2004 are presented. 392 had surgery via a middle fossa, 146 via a translabyrinthine approach. RESULTS: Shortly after surgery 82.2 % of patients showed no facial palsy. 74 patients had an incomplete, 7 a complete paresis. After 12 months 144 of the patients operated on via middle fossa approach showed no palsy, 13 had an incomplete and one a complete paresis. Out of 76 patients operated on translabyrinthine approach 75 had no paresis, one had an incomplete, and no patient had a complete paresis. There was no difference between intrameatal tumors and tumors extending beyond the porus. Regular facial nerve function was seen in 93 %, postoperatively. Permanent paresis was seen in 0.4 % of cases. CONCLUSION: Acoustic neuroma confined to the internal meatus or with minor extension into the cerebello-pontine angle (i. e. no contact to structures of the brain stem or vessels of the posterior fossa) are feasible for resection via a middle fossa or translabyrinthine approach. The possibility of hearing preservation combined with low morbidity and good results of facial nerve function makes these approaches the treatment of choice for this group of tumors.

[Doubling of the pinna, a rare branchial arch developmental disorder]. / Doppelanlage der Ohrmuschel, eine seltene Kiemenbogen-Fehlbildung.

BACKGROUND: Auricular appendices are not unusual, but doubling of the pinna is rare. There is still a controversy if these are derivates from the first or the second branchial arch. PATIENT: The case of a 3 year old girl is described with doubling of the pinna and hemi facial atrophia. The second pinna was on third of the orthotop regular auricle. It seemed to come from the tragus anlage i. e. originating from the first otic hillock. RESULTS: The accessory pinna was resected, an aesthetic result could be achieved. CONCLUSION: Morphology and position of accessory pinnas arise again the question of the origin of the auricular hillocks. This case supports the opinion of Otto that the first hillock only belongs to the first branchial arch and the major part of the auricle is originating from the hillock 2-6 i. e. to the second branchial arch.

[Infected parotid cyst as a cause of facial palsy]. / Infizierte Parotiszyste als Ursache einer Fazialisparese.

BACKGROUND: Inflammatory processes are a rare cause of peripheral facial palsy. In most cases even massive infection does not lead to a loss of facial nerve function. In the literature, only 8 cases of facial paralysis associated with parotid cyst have been described. PATIENT AND RESULTS: We present a case of facial palsy caused by an inflamed cyst of the parotid gland. The patient was operated on with the diagnosis malignant parotid tumor. The pathological report showed a squamous epithelial cyst, massive lymphocytic infiltration. CONCLUSIONS: As a rule the combination parotid gland lesion and facial palsy is a sign of malignancy, clinicians should be aware that, on rare occasions, facial nerve dysfunction may result from benign parotid gland disease.

[Malignant paranasal sinus tumors. Diagnosis, therapy and results]. / Maligne Nasennebenhöhlentumoren. Diagnostik, Therapie und Ergebnisse.

BACKGROUND: Malignant neoplasmas of the paranasal sinuses are rare and present usually in advanced tumor stage due to the lack of early clinical symptoms. PATIENTS AND METHODS: In the last 10 years, 63 patients with paranasal malignancies were treated at the Department of Otolaryngology, Head and Neck Surgery of the University of Würzburg. 33% of the patients showed an occupational exposition (wood-processing or metal industry). At the time of the first visit to our institution 95% of the patients presented with an extensive disease, staged T3 and T4. Adenocarcinoma (24%), squamous cell carcinoma (22%) and malignant melanoma (19%) were the most common histologies. Surgery combined with radiotherapy was the treatment strategy in 55 patients (87%). RESULTS: Patients with a complete surgical resection showed a higher 5-year-survival rate (77%) than patients with an incomplete resection (56%). In 38% (n=21) of the patients treated with surgery and radiotherapy, a local recurrence of the tumor was observed. This recurrence localised in the skull base and/or the orbita/periorbita occurred most frequently in the first (46%) or the second year (31%). CONCLUSION: The prognosis of malignant paranasal tumors depends mainly on the control of the local tumor growth. Modern strategies of surgical treatment in combination with radiotherapy need to be implemented in an effort to achieve a continuous remission.