Möglichkeiten und Grenzen der apparativen Hörverbesserung

Ohne ZusammenfassungHerrn ProfessorZange zum 60. Geburtstag.     

Möglichkeiten und Grenzen der Dopplersonographie im Kopf-Hals-Bereich

Sonography has provided an important addition to the tools available for the diagnosis of the soft tissues in the head and neck region. The ENT surgeon himself is able to examine pathological formations by this quick, non-invasive and, last but not least, less expensive method. Due to the high resolution of the procedure the chance of detecting even small changes is increased and the exactness of diagnosis of pathological lymph nodes of the neck has been significantly improved compared to palpation alone. Ultrasound has replaced the sialographic procedures in the field of diagnostic evaluation of salivary gland disease in the daily practice except for special indications. After inauguration of color Doppler sonography non-invasive evaluation of vascular stenosis of the large cervical vessels concerning their hemodynamic effects has become possible. This issue is important for the differential diagnosis of otoneurological diseases such as sudden hearing loss, vertigo and tinnitus. Additionally, the extent of perfusion of space-occupying lesions can be easily examined, and therefore the risk of mass bleeding can be preoperatively assessed by this method without harm to the patient. Especially carotid body tumors may be diagnosed with high accuracy by the evidence of significant diffuse perfusion of the lesion. In several studies the specificity of the assessment of cervical lymph node disease could be increased by examination of resistance indices. However, other authors have shown inconsistent results in differentiation of benign and malignant lumps; therefore, final judgment does not seem to be possible yet. Use of echo-contrast agents to enhance the ultrasound signal seems to be a promising approach for future developments in color Doppler imaging.     

Möglichkeiten und Grenzen moderner Embolisationsverfahren

Correct clinical and angiographic classification of vascular anomalies, including consideration of their flow pattern (high-flow versus low-flow), is the basis of accurate indications for minimally invasive therapy modalities such as embolization. Technical advancements and miniaturization of catheter materials (including steerable microwires, flow-directed microcatheters and detachable tips) gained access for embolotherapy to lesions anywhere in the body. The aim of embolization, which is mainly indicated for therapy of high-flow arteriovenous malformations, is the complete, permanent occlusion of the lesion nidus. Nowadays, embolotherapy is performed using permanent liquid embolization agents, in multiple staged sessions. This technique reduces complications such as ischemic necrosis and peripheral nerve lesions compared to alcohol embolization. Sole occlusion of the arterial inflow by surgical resection or interventional coil application is considered obsolete. The size of the lesion and the high treatment costs limit the use of embolotherapy.     

Möglichkeiten und Grenzen einer Abbildung der HNO-Heilkunde im G-DRG-System

Background

To improve the representation of ENT medicine in the German diagnosis related groups (G-DRG) reimbursement system, the German Association for ENT Medicine and the ENT Professional Medical Association, in cooperation with the DRG-Research Group of the University Hospital of Muenster, undertook a DRG evaluation project.

Method

A retrospective analysis was carried out of the DRG data records from 93,605 cases taken at 39 ENT institutions in 2003. A prospective collection of data from 25,666 cases, including defined expenditure data within a 4 month period in 2004, was also made.

Results

The number of cases per ENT institution ranged from 274 to 2,556. The mean case-mix was 792.0 and the mean case-mix index was 0.84. A total of 60.5% of the patients were male and 39.5% female, with an average age of 43.3 years. The mean patient clinical and complexity level (PCCL) was 0.72. Considerable adjustments have to be made, especially in oto-, rhino- and sinus-surgery. Allocation according to the complexity of the surgical procedure is mandatory and requires a revision of the German Catalogue of Medical Procedures. A DRG differentiation based on the PCCL should be implemented more frequently. Diagnostic endoscopies should be allocated via surgical partitioning.

Conclusion

The adjustment proposals based on these results will gradually lead to an improved allocation of ENT medical procedures within the G-DRG system in 2006 and later.

     

Möglichkeiten und Grenzen der Farbstofflasertherapie bei kapillären Malformationen

Capillary malformations (port-wine stains) are observed in less than 1?% of neonates and may occur coincidentally with other vascular and nonvascular malformations. Two thirds of lesions occur in the head and neck area and may have important cosmetic and psychological implications for the patients. Treatment with flashlamp-pumped pulsed dye lasers is still the therapy of choice for capillary malformations and can be applied to infants. If the laser device is used appropriately, the rate of persistent side effects is low. Although laser treatment achieves good clearance in the majority of patients with capillary malformations, complete clearance is rare. New therapeutic options are thus urgently required.     

Möglichkeiten und Grenzen der flexiblen chirurgischen Laryngoskopie in Lokalanästhesie

Microsurgery of the larynx is commonly performed as direct laryngoscopy (DL) under general anesthesia. An alternative in selected cases is flexible laryngoscopy (FSL) under local anesthesia. We used a flexible laryngoscope that contained an additional working tunnel (Olympus ENF Type T3). Local anaesthesia of the larynx was achieved with 1% oxybuprocaine-HCl. Tissue samples were taken under endoscopic view and control. Twenty-five patients were studied and had benign lesions of the larynx or were being followed after treatment for cancer. The examination was tolerated well by all patients. The handling of the endoscope allowed precise targeting and sample taking. Due to the 2.2 mm diameter of the forceps the sizes of the biopsies were also limited. However, nearly all of the biopsies taken allowed sufficient histological examination. The advantage of the FSL was its simplicity and the minor inconvenience for patients. Although true histological results of suspect findings are possible, limitations in examining the hypopharynx prevent true staging of cancer patients. In general, FCL is a worth-while complement to DL.     

M?glichkeiten und Grenzen der Fr��herkennung von Sprachentwicklungsst?rungen

Background

It is not been proven to date that children with developmental language disorders can be identified by general language screening in 2-year-old children. The goal of the present study was to determine the predictive diagnostic power of the parent questionnaire SBE-2-KT.

Methods

The language abilities of 562 children were assessed using the SBE-2-KT at the age of 2 and reassessed 1?year later using the parent questionnaire SBE-3-KT.

Results

The correlation between language scores at age 2?and 3 were moderate and highly significant (r_Sp=0.59?C0.68, p<0.001). Sensitivity, specificity, as well as positive and negative predictive values against language impairment at age 3 as a reference were 43%, 93%, 57% and 88%, respectively.

Conclusions

The possibility to identify children with language disorders at the age of 2 is limited. Almost half of the children with delayed language development at age 2 had results on language screening within the normal range at 3?years. Furthermore, nearly every second child with subnormal language scores at age 3 is not classified as a late talker at age 2. Therefore, for early identification of language disorders a general reassessment of language skills is necessary at the age of 3.     

M?glichkeiten und Grenzen der flexiblen chirurgischen Laryngoskopie in Lokalan?sthesie

Einleitung: Mikrochirurgische Eingriffe am Larynx werden normalerweise als direkte Laryngoskopie (DL) in Narkose durchgeführt. Als Alternative bietet sich bei bestimmten Indikationen die flexible chirurgische Laryngoskopie (FCL) in Lokalan?sthesie an.     

Fehlermöglichkeiten in der Ton- und Sprachaudiometrie

Langenbeck, einer der bekanntesten Begründer der praktischen Audiometrie in Deutschland, beschrieb das Audiometrieren als eine ?rztliche Kunst, die ebenso wie das Otoskopieren von Ohr, Nase und Kehlkopf zum Handwerk des Hals-Nasen-Ohren-Arztes geh?re. Neben Audiologie-Assistentinnen und -Assistenten, die in speziellen Ausbildungsg?ngen an audiologisch versierten Einrichtungen ausgebildet worden sind, werden jedoch in HNO-Arztpraxen überwiegend Arzthelferinnen mit der Audiometrie besch?ftigt, die sich ihre Fertigkeiten und ihr Wissen günstigstenfalls in Fortbildungskursen und Lehrg?ngen angeeignet haben. Da jedoch die Aus- und Weiterbildung der nichtmedizinischen Mitarbeiter in der Audiologie ebenso wie die der angehenden oder ausgebildeten HNO-?rzte im Bereich der Audiometrie h?ufig noch sehr unbefriedigend ist, müssen sowohl HNO-?rzte als auch andere mit der Audiometrie besch?ftigte ?rzte über die Fehlerm?glichkeiten in der Audiometrie informiert sein, um im Rahmen der H?rschwellendiagnotik, der überschwelligen Diagnostik sowie bei der Sprachaudiometrie eventuelle Fehler zu erkennen. Dies gilt natürlich auch und in besonderem Ma?e für die Mitarbeiterinnen und Mitarbeiter, die die audiologischen Untersuchungen durchführen.     

Therapie der tracheoösophagealen und tracheopharyngealen Fisteln nach Laryngektomie

Tracheoesophageal (TEF) and tracheopharyngeal fistulas (TPF) after laryngectomy can mainly be divided into five types: “high TEF with leakage through the voice prosthesis (VP)” (Type Ia), “high TEF with leakage around the VP” (Type Ib), “enlarged high TEF” (Type II), “deep TEF” (Type III), “TPF” (Type IV) and “TPF associated with pharynx stenosis” (Type V). Leakage of TEF in prosthetic voice restoration usually responds well to conservative measures. If these measures fail, as well as in all cases of TPF, surgical intervention is necessary for transtracheostomal or transcervical closure with multi-layer sutures of the esophagus and trachea. In persisting TEF/TPF after unsuccessful surgical attempts revision surgery remains challenging. Tracheostoma transposition for dissociation of the cranial end of the trachea and the hypopharynx and esophagus is essential for effective closure. In rare cases of TPF combined with pharyngoesophageal stricture formation a resection and immediate reconstruction of the stenotic pharyngoesophageal segment with a tube-shaped fasciocutaneous radial forearm flap must be considered.