[Updated S2k AWMF guideline on obstructive sialadenitis]. / Aktualisierte AWMF-S2k-Leitlinie zur obstruktiven Sialadenitis.

The update of this guideline was an important step to define standards for the use of sialendoscopy and other emerging minimally invasive techniques for the therapy of sialolithiasis and other obstructive salivary gland diseases. The current actualization was necessary to adapt the diagnostic and therapeutic algorithms to the current scientific knowledge. In this article they are presented in a shortened version with a focus on conservative therapeutic measures which are especially relevant for daily practice.

Antero- vs. retrograde nerve dissection in parotidectomy: a systematic review and meta-analysis.

INTRODUCTION: The retrograde approach (RP) to nerve identification is a method seldom used in parotid surgery. A systematic review comparing this method to the standard anterograde approach (AP) with respect to facial nerve palsy (FNP) does not currently exist. METHODS: In a meta-analysis according to the PRISMA statement, eight publications, including one randomized controlled trial, were selected. The primary aim was to compare the temporary and permanent FNP resulting from the two dissection methods. Facial nerve function was graded according to the House-Brackmann Scale. The secondary goal was a comparison of the cut-suture times (CST), the volume of healthy tissue (VHT) dissected, the rates of postoperative hematoma (PH), and postoperative infection (PI). RESULTS: Temporary FNP was noted in 18.2% in the RP group as well as in 34.4% in the AP group. Permanent FNP occurred in 0.9% RPs and 2.4% APs. According to the mixed-effect logistic regression model, there was no significant difference between the two groups in the pooled odds ratio (OR) for either temporary [OR 2.64, 95% confidence interval (CI) 0.97-7.21] or permanent FNP (OR 4.31, 95% CI 0.44-42.28). The CST was significantly shorter in the RP group (p = 0.005), with a significantly smaller VHT dissected (p < 0.0001). There were no differences regarding PH and PI. CONCLUSION: The RP is a safe procedure with no significant difference in FNP rates when compared to the AP and, considering the shorter CST and the lesser VHT resected in the RP, it is superior to the AP. Surgeons engaged in parotidectomy should be familiar with both methods of dissection.

Hyperplasia and the degree and activity of inflammation in chronic recurrent tonsillitis: a histopathological study.

Postoperative haemorrhage following tonsillectomy occurs in 5.98% of all cases with up to 10 deaths reported annually in Germany. When comparing tonsillectomy (TE) and tonsillotomy (TT), the same long-term frequency of ENT infections is displayed in children and young adults. However, taking postoperative haemorrhaging into account, TT is more favourable. Chronic tonsillitis is one of the most common indications for TE in the adult population; however, a histopathological characterization may reveal objective criteria and provide a foundation for routinely performing TT in adults too. Three essential parameters hyperplasia (HP), grade of inflammation (GOI) and activity of inflammation (AOI), which are responsible for, and associated with a clinically relevant disease were histopathologically examined in the tonsils of 100 adult patients with chronic recurrent tonsillitis. The parameters were analysed and compared separately in the pharyngeal and basal parts of the tonsils as well as in three sections (upper and lower pole of the tonsil, middle part) as this may influence the indication for TT. The comparison of the basal and pharyngeal portions displayed a significant difference in the GOI and the HP in all three sections: grade 2 HP as well as GOI were more commonly found in the basal than pharyngeal portions (p > 0.001). AOI (grade 2) displayed the same properties in the middle section (p < 0.002), but did not reach statistical significance in the cranial and caudal sections (p = 0.107 and p = 0.186). An overabundance of grade 1 GOI, AOI, and HP was seen in the pharyngeal sections. The results show that two out of three relevant parameters that demonstrate histopathological changes in recurrent inflamed tonsils have a significantly stronger presence in the basal section of the tonsil as opposed to the pharyngeal section. The processes initiated by inflammation next to the surface responsible for a clinically relevant recurrent tonsillitis seem to cause stronger reactions in the deep follicular portion of the tonsils.

Visualization of anatomy in normal and pathologic middle ears by cone beam CT.

Cone beam computed tomography (CBCT, syn. digital volume tomography = DVT) was introduced into ENT imaging more than 10 years ago. The main focus was on imaging of the paranasal sinuses and traumatology of the mid face. In recent years, it has also been used in imaging of chronic ear diseases (especially in visualizing middle and inner ear implants), but an exact description of the advantages and limitations of visualizing precise anatomy in a relevant number of patients is still missing. The data sets of CBCT imaging of the middle and inner ear of 204 patients were analyzed regarding the visualization of 18 different anatomic structures. A three-step scale (excellent visible, partial visible, not visible) was taken. All analyses were performed by two surgeons experienced in otology and imaging. The indications for imaging were chronic middle ear disease or conductive hearing loss. Previously operated patients were excluded to rule out possible confounders. In dependence of a radiological pathology/opacity of the middle ear, two groups (with and without pathology) were built. Regarding the possibility of excellent visualization, significant differences were only found for small bony structures: incu-stapedial joint (25.8 vs. 63.5 %), long process of incus (42.7 vs. 88.8 %), head of stapes (27.0 vs. 62.6 %), anterior crus of stapes (16.9 vs. 40.9 %) and posterior crus of stapes (19.1 vs. 42.6 %). The other structures (semicircular canals, skull base at mastoid and middle ear, jugular bulb, sinus sigmoideus, facial nerve) could be visualized well in both groups with rates around 85-100 %. Even CBCT shows little limitations in visualization of the small structures of the middle and inner ear. Big bony structures can be visualized in normal as well as in pathologic ears. Overall, due to pathology of middle ear, an additional limitation of evaluation of the ossicular chain exists. In future, studies should focus on comparative evaluation of different diseases and different radiological modalities and be performed by radiologists and otologists together to improve the quality of reports and to answer clinical questions more satisfactorily.

Oncological and surgical outcome of total laryngectomy in combination with neck dissection in the elderly.

There are controversial data on oncological and surgical outcome after major head and neck cancer surgery in the elderly. The aim of this study was to evaluate the outcome of elderly cancer patients after total laryngectomy in combination with neck dissection. A total of 58 patients separated into two age groups (28 < 65 vs. 30 ≥ 65 years) with hypopharyngeal and laryngeal cancer who underwent total laryngectomy and neck dissection were enrolled. Comorbidities of both age groups using the Charlson comorbidity index, hospitalization days as well as surgical complications evaluated by the Clavien-Dindo classification were examined. Overall and disease-free survivals of all patients were analyzed. The average follow-up was 2.9 years. Surgical complication rate was significantly increased in elderly (p = 0.04). However, complications could be treated without surgical intervention in most cases without significant extension of hospitalization. Locoregional and distant control did not significantly differ in both age groups. Disease-free and overall survival showed no significant differences for the two age groups by the Kaplan-Meier analysis (p = 0.66 and 0.08, respectively). Total laryngectomy in combination with neck dissection can be considered in elderly patients with satisfactory oncological and surgical outcome.

Toxic inner ear lesion following otitis media with effusion: a comparative CT-study regarding the morphology of the inner ear.

Viral infections of the upper respiratory airways can lead to a delayed viral otitis media (VOM) caused by a diffusion of viruses/virus particles through the round window membrane and resulting in sensorineural hearing loss. The treatment of choice is immediate paracentesis, evacuation of all fluids from the middle ear cavity, and haemorrheological infusions. However, in some cases, persistent symptoms may be an indication for a surgical approach using mastoidectomy. In high-resolution computed tomography, an extended small-sized pneumatisation of the mastoid cells with complete shading was found in these non-responsive cases. Therefore, a direct means of inner ear affliction through weak parts of the labyrinthine bone may be hypothesised. Patients suffering from a toxic inner ear lesion (TIEL) following a common cold, treated over a 10-year period in a Tertiary Care Centre (N = 52, 57 ears), were identified and the morphological characteristics of the temporal bones of affected patients were examined by means of high-resolution computed tomography (hrCT). The findings were compared with a matched control group of 64 normal ears (CONT). Measurements included the grade of pneumatisation, distances within the temporal bones and Hounsfield units (HU) at defined anatomical structures. In the TIEL group, we found a small-sized pneumatisation in 79.4 % and a medium-sized pneumatisation in 10.9 %, thus differing from the CONT group and the literature data. Thickness of the bone wall of the lateral semicircular canal (LSC) and distances within the aditus ad antrum were significantly reduced in the TIEL group. HU's were markedly lower in the TIEL group at the precochlea, the LSC, and dorsolateral to the promentia of the LSC. There was a correlation between the HU's at the prominentia of the LSC and the hearing loss (p = 0.002). Persisting interosseous globuli, as described in 1897 by Paul Manasse, form an osseochondral network within the otic capsule and may be responsible for a direct means of toxic inner ear infection. The CT-morphometric results support this thesis. In the group of these patients (TIEL) a CT-scan and in non-responders to conservative treatment a surgical approach by mastoidectomy is recommended.

Is elective neck dissection indicated during salvage surgery for head and neck squamous cell carcinoma?

Among patients with head and neck squamous cell carcinoma with a negative neck who are initially treated with (chemo)radiotherapy, a number of cases will recur locally without obvious neck recurrence. There is little information available as to the most efficacious management of the neck in these cases. We have reviewed the literature to see what conclusions can be drawn from previous reports. We conducted a bibliography search on MEDLINE and EMBASE databases. Studies published in the English language and those on squamous cell carcinoma of the oral cavity, nasopharynx, oropharynx, larynx and hypopharynx were included. Data related to neck management were extracted from the articles. Twelve studies satisfied the inclusion criteria. Five studies reported only one treatment plan (either neck dissection or observation), while the others compared neck dissection to observation. The rate of occult metastases ranged from 3.4 to 12 %. The studies included a variable distribution of primary sites and stages of the recurrent primary tumors. The risk of occult neck node metastasis in a clinically rN0 patient correlated with tumor site and T stage. Observation of the neck can be suggested for patients with T1-2 glottic tumors, who recurred with less advanced tumors (rT1-2). For patients with more advanced laryngeal recurrences or recurrence at other high-risk sites, neck dissection could be considered for the rN0 patient, particularly if the neck was not included in the previous radiation fields.

Epidermal growth factor-induced modulation of cytokeratin expression levels influences the morphological phenotype of head and neck squamous cell carcinoma cells.

The migratory ability of tumor cells requires cytoskeletal rearrangement processes. Epidermal growth factor receptor (EGFR)-signaling tightly correlates with tumor progression in head and neck squamous cell carcinomas (HNSCCs), and has previously been implicated in the regulation of cytokeratin (CK) expression. In this study, HNSCC cell lines were treated with EGF, and CK expression levels were monitored by Western blot analysis. Changes in cellular morphology were documented by fluorescence- and atomic force microscopy. Some of the cell lines demonstrated an EGF-dependent modulation of CK expression levels. Interestingly, regression of some CK subtypes or initial up-regulation followed by downregulation at higher EGF-levels could also be observed in the tested cell lines. Overall, the influence of EGF on CK expression levels appeared variable and cell-type-dependent. Real-time cellular analysis of EGF-treated and -untreated HNSCC cell lines demonstrated a rise over time in cellular impedance. In three of the EGF-treated HNSCC cell lines, this rise was markedly higher than in untreated controls, whereas in one of the cell lines the gain of cellular impedance was paradoxically reduced after EGF treatment, which was found to correlate with changes in cellular morphology rather than with relevant changes in cellular viability or proliferation. After treating HNSCC cells with EGF, CK filaments frequently appeared diffusely distributed throughout the cytoplasm, and in some cases were found in a perinuclear localization, the latter being reminiscent to observations by other groups. In summary, the data points to a possible role of EGFR in modulating HNSCC cell morphology.

Back to the roots of Warthin's tumor of the parotid gland.

The exact etiopathogenesis of the Warthin's tumor of the parotid gland is still unclear. Since the time of the first histological description of this lesion by Hildebrand and later Albrecht and Arzt many different partly confusing hypothesis about pathogenesis of Warthin's tumor were introduced. However, the review of published data about the pathogenesis of this lesion revealed that recent literature is in conformity with the supposed hypothesis about pathogenesis of Warthin's tumor of those authors about the origin of this lesion from lymph nodes almost a century ago.

Effect of postoperative systemic prednisolone on short-term and long-term outcomes in chronic rhinosinusitis with nasal polyps: A multi-centered randomized clinical trial.

Introduction: The objective of this study was to determine whether postoperative additive systemic steroid administration in chronic rhinosinusitis with nasal polyps (CRSwNP) impacted selected endoscopic, subjective and objective outcome measures. Methods: This was a prospective, randomized, double-blind, placebo-controlled, noninferiority multicenter trial of n=106 patients with CRSwNP. All patients underwent primary functional endoscopic sinus surgery (FESS) followed by topical nasal steroids. Patients were randomized to a systemic steroid or placebo for 1 month. Patients were followed up for 2 years over 9 time points. The primary outcome measures were the differences between groups with respect to the nasal polyp score (NPS) and sinonasal quality of life (SNQoL). Secondary outcome measures included interactions with respect to the Lund-Kennedy score (LKS), sinonasal symptoms, general quality of life (GQoL), 16-item odor identification test scores, recurrence rates, need for revision surgery and mucus biomarker levels. Results: 106 patients were randomized to either the placebo or the systemic steroid group (n=53 per group). Postoperative systemic steroids were not superior to placebo with respect to all primary (p= 0.077) and secondary outcome measures (p>0.05 for all). Reported adverse events were similar between the two groups. Conclusion: In conclusion, the addition of postoperative systemic steroids after primary FESS did not confer a benefit over topical steroid nasal spray alone with respect to NPS, SNQOL, LKS, GQOL, sinonasal symptoms, smell scores, recurrence rates, the need for revision surgery or biomarkers over a short-term follow-up of up to 9 months and a long-term follow-up of up to 24 months in CRSwNP patients. Functional endoscopic surgery did, however, show a strong effect on all outcome measures, which remained relatively stable up to the endpoint at 2 years.

Port-wine stains are more than skin-deep! Expanding the spectrum of extracutaneous manifestations of nevi flammei of the head and neck.

UNLABELLED: It is well known that port-wine stains of the upper part of the face may herald abnormalities of the brain or eye in the form of Sturge-Weber syndrome. This study focuses on other extracutaneous anomalies in patients with nevi flammei of the head and neck, giving rise to functional complications. PATIENTS AND METHODS: A retrospective study was performed on patients with port-wine stains involving the head and neck area. Records were reviewed for demographic parameters, extent of the lesion, clinical complications, diagnostic measures, previous treatments, ultimate therapeutic approach, and outcome. RESULTS: Nine patients, mean age 50.4 years, with port-wine stains and clinical symptoms due to extracutaneous involvement, were admitted and treated from 2006 to 2009. Major clinical features included macrocheilia in three cases, gingival bleeding in two, dysphonia with globus sensation, painful parotideal swelling with recurrent otitis, painful lingual swelling, recurrent epistaxis, and nasal obstruction in one case each. Cases with lower lip hypertrophy were treated by conventional surgical approaches. Recurrent epistaxis and nasal obstruction due to affected inferior turbinate were treated by Nd:YAG laser therapy, and globus sensation and dysphonia by speech therapy. Patients with gingival affection and recurrent otitis were treated by local ear care. CONCLUSION: Port-wine stains in the head and neck may develop extracutaneous manifestations causing severe problems. A multimodal and interdisciplinary approach is mandatory for an appropriate treatment.

Delayed lymph node metastases after elective neck dissection in patients with oral and oropharyngeal cancer and pN0 neck.

PURPOSE: Patients with surgically treated head and neck cancer and clinical N0 neck with high risk of occult lymph node metastasis undergo elective neck dissection (ND). Late lymph node metastasis may appear in those patients with pN0 neck. The aim of the present study was to analyze the incidence and clinical relevance of late lymph node metastasis in patients with head and neck cancer. MATERIALS AND METHODS: The clinical data of 61 patients with head and neck cancer who had undergone elective ND with pN0 neck were retrospectively analyzed. Only patients without local failure, second primary, or radiochemotherapy were included in the study. RESULTS: Late lymph node metastasis could be observed in 4 (6.5%) cases at the margin or outside the initially dissected lymph node levels. In those patients, the primary tumor was localized in the oral cavity (n = 3) or oropharynx (n = 1) and was classified in all cases as T1 or T2. Lymph node metastasis could be found in levels I (n = 2), II (n = 1), and IV (n = 1), respectively. CONCLUSION: Even in the case of pN0 neck after an elective ND, the appearance of late lymph node metastases must be expected. The low proportion of patients with late lymph node metastases after a selective ND in clinical and histologic N0 does not justify an extended form of neck surgery.

MMP-2 expression in 102 patients with glottic laryngeal cancer.

In order to evaluate the potential of matrix metalloproteinase 2 (MMP-2) as a prognostic factor for glottic laryngeal cancer. One hundred and two surgical specimens from patients with glottic laryngeal cancer who underwent laryngectomy for their disease in the University Hospital of Patras, Greece from 1998 to 2005 were reviewed retrospectively regarding MMP-2 expression via immunohistochemistry. Immunostaining was performed using a streptavidin-biotin peroxidase complex technique (LSAB). Results revealed that 54 of 102 patients (52.9%) had positive cytoplasmic staining for MMP-2. Kaplan-Meier analysis demonstrated statistically significant difference (p = 0.037) for the 5-year overall survival rate between the groups with positive and negative MMP-2 expression, and marginal statistical significance for the disease free survival rate (p = 0.048). The capsule rupture of metastatic lymph nodes and MMP-2 expression in primary tumor site also seems to be related (p = 0.047). Statistical significance could not be established between MMP-2 expression and the clinicopathological features of the disease (T stage, N stage, clinical stage, differentiation). In conclusion, MMP-2 expression was related with worse overall and disease-free survival and could be considered as a potential marker of poor prognosis.

Low flow vascular malformations of the head and neck: a study on brightness mode, color coded duplex and spectral Doppler sonography.

The clinical presentation of low flow vascular malformations of the head and neck (LFVM) can range from a birthmark to severe disfigurement, functional impairment or relevant hemorrhage. The values of Brightness mode (B-mode) ultrasound and Doppler sonography in the investigation, identifying and differentiating of these lesions has been sparingly documented in the literature. This study evaluates the sonografic features of different morphological subtypes of LFVM. This is a 2-year retrospective study of 51 patients who presented with LFVM based on routine ultrasound exam in the context of their clinical consultation. Diagnosis was based on the clinical and histological findings. B-mode, color coded duplex and spectral Doppler measurements were performed for venous, lymphatic, capillary, and mixed venous-lymphatic lesions of the head and neck. The echogenicity of the majority of venous malformations was heterogenic, of most lymphatic malformations hypoechoic, and of all capillary malformations isoechoic. Blood flow was detected in only 11 cases (36.7%) of venous malformations with a monophasic pattern. There was a statistical significant difference in the mean minimum and maximum Doppler shifts between venous and lymphatic malformation for cases when the blood flow was evident. No statistical significant difference in Doppler parameters existed between capillary and lymphatic, neither between venous and capillary nor mixed malformations. Phleboliths were present in eight cases (26.7%) of venous malformations and were not detectable in any other subtype of LFVM. The detection of flow in ultrasound was only possible in a small portion of LFVM. When considering differentiating among LFVM, features such as the echogenecity, spectral Doppler wave forms, and the evidence of phleboliths contribute to establish the correct diagnosis.

Temporal bone imaging using digital volume tomography and computed tomography: a comparative cadaveric radiological study.

PURPOSE: The aim of the present study was to analyze the diagnostic value of some temporal bone structures, e.g., ossicular chain, with digital volume tomography (DVT) compared with computed tomography (CT). METHODS: Radiological imaging for presentation structures of the temporal bone were performed by DVT and CT. Axial and coronal scans in vitro examinations were performed in 38 human temporal bones. 43 structures were defined. The frequency of visualization of these anatomic structures were studied and statistically analyzed. RESULTS: In the present study there was a higher significance of identified structures in DVT. In 15 (34.9%) temporal bone specimens defined structures were found equally in DVT and CT scans of axial images and 12 (27.9%) of coronal images. However, 9 structures (20.1%) of axial scans and 5 structures (11.6%) of coronal scans could be identified statistically significantly (P < 0.05) more often in DVT than in CT. CONCLUSION: Anatomical structures of the temporal bone can be identified in higher significance in DVT than in CT scans.

The value of digital volume tomography in assessing the position of cochlear implant arrays in temporal bone specimens.

OBJECTIVES: Radiological evaluation of the position of cochlear implant (CI) devices is an upcoming method for quality control after CI surgery. First, results of imaging of the middle and inner ear with digital volume tomography (DVT) show considerable advantages such as exceptional image quality, thin slice thickness, and low radiation dose. The aim of this study was to evaluate whether DVT is an appropriate method for postoperative imaging of CI patients and to identify the exact position of the implant array within the cochlear by multiple measurements. DESIGN: Thirteen formalin-fixed temporal bone specimens were implanted with a CI array and scanned in DVT. To determine the exact electrode position, these specimens were ground and stained for microscopic measurements. The measurements on grindings acted as a referee and were compared with the measurements in DVT scans. The statistical analysis between the two measurement protocols was performed using the Bland-Altman method. RESULTS: Best achievable agreement between DVT scans and histological reference was shown. Mean differences between DVT and grindings from -1.55 to -65.40 microm were calculated. All means are within the region of accuracy. General positioning of the implant into the cochlea could be verified in all specimens. The exact position of the implanted array within the cochlear scalae could be recognized correctly in 11 of 13 cases in DVT. It was possible to identify shiftings between the tympanic and vestibular scalae in all cases. CONCLUSION: DVT seems to be a convenient technique for postoperative position control after cochlear implantation.

Laser treatment of mucosal venous malformations of the upper aerodigestive tract in 50 patients.

We examined the clinical appearance of mucosal venous malformations of the upper aerodigestive tract with regard to their accessibility to laser therapy and further assessed the value of treatment of these lesions with the Nd:YAG and CO(2) lasers. A retrospective study was performed in 50 patients who had undergone laser treatment for mucosal low-flow vascular malformations of the upper aerodigestive tract. Records were reviewed for demographic data, extent of the lesion, treatment modality, required number of therapy sessions and the therapeutic outcome. Follow-up was performed by postinterventional clinical examination and additional interview by phone for current status. Between 1 July 2001 and 30 September 2008 32 women and 18 men received laser treatment and were followed up until 30 June 2009. The lesions were classified into three grades according to their extent and clinical presentation, as follows: grade 1 <2 cm, asymptomatic or mild symptoms; grade 2 2-4 cm, asymptomatic or mild symptoms; and grade 3 > or =4 cm or multiple locations (more than two) or severe symptoms such as dyspnoea, pain or dysphagia. Of the 50 patients, 13 (26%) were classified as having grade 1 disease, 22 (44%) grade 2 disease, and 15 (30%) grade 3 disease. Treatment in 39 patients was solely with the Nd:YAG laser using the noncontact or interstitial technique. Resection using the CO(2) laser was performed in six patients, and combined conventional surgery and Nd:YAG laser therapy in five patients. The applied grading reflects the extent of laser therapy and also the number of therapy sessions performed in patients treated with the Nd:YAG laser. Resection with the CO(2) laser is suitable for grade 1 lesions. In advanced lesions a combined therapeutic approach and multiple sessions are necessary. The Nd:YAG laser is still a valuable therapeutic tool for the treatment of venous malformations of the mucosa.