ASS-Toleranzinduktion

Aspirin desensitization has established itself as an additional therapy option in the treatment of aspirin- exacerbated respiratory disease, recurrent chronic rhinosinusitis and nasal polyps. Inpatient treatment is strongly recommended due to the risk of life-threatening side effects. In addition, the necessary requirements, indications and contraindications should be carefully considered from a medicolegal perspective. A maintenance dose of 300 (-500) mg ASS is currently recommended. Indications include persisting symptoms despite intensive medical care and/or recurrent nasal polyps, leading to recurrent sinus operations and/or the need to take systemic corticosteroids in order to control nasal symptoms or asthma. If ASS intake is interrupted for more than 48 h, aspirin desensitization should be resumed to prevent renewed intolerance reactions.     

Vestibuläre Paroxysmie

The diagnosis and treatment of vertigo are very common in ear nose and throat medicine and neurology. As our case report demonstrates, an interdisciplinary approach is often useful for finding the correct diagnosis. Diagnosing disabling positional vertigo now seems uncomplicated using special MRI. More important is the history of frequent, short-term vertigo, sometimes accompanied by tinnitus. In analogy to trigeminal neuralgia, treatment should be started with carbamazepine or similar drugs. If unsuccessful, microvascular decompression as a neurosurgical intervention is recommended.     

Acute bacterial sinusitis in adults: management in the primary care setting

Sinus disease is inherently associated with viral upper respiratory tract infections and occurs in 90% of individuals with the common cold. Acute bacterial sinusitis occurs in 0.5 to 2% of these individuals. Although the diagnosis of acute bacterial sinusitis is usually based on physical findings, no one sign or symptom is either sensitive or specific for sinusitis. The predictive power can be significantly improved when all signs and symptoms are combined into a clinical impression. Imaging studies have not been shown to be cost effective in the initial assessment and treatment of patients in the primary care setting. Simple plain films may be indicated to resolve the diagnosis in patients with an equivocal history or to follow patients admitted to hospital with severe sinus disease. The initial management of acute sinusitis should be directed toward the relief of symptoms with a 7-day course of decongestants and mucoevacuents. For patients who fail to improve with symptomatic treatment, a 10-day course of amoxicillin is recommended. Second line antibiotics should be initiated if improvement is not seen within 72 to 96 hours.     

From Killian's submucous septum resection and Cottle's septoplasty to modern plastic septum correction and functional septo-rhinoplasty

Killian's submucous resection of the septum and Cottle's septoplasty are still described in textbooks and journals as alternative methods of treatment for septal deformities. It is the aim of this paper to show that Killian's submucous septal resection and Cottle's "maxilla-premaxilla" approach are only mile stones on the road to the modern plastic surgery of the septum. It is recommended that the names of Killian and Cottle should be dropped, and it would be better to use the terms septoplasty or plastic surgery of the septum, if deformities of the septum should be treated. These techniques also changed the methods of rhinoplasty and lead to functional septorhinoplasty.     

Desmoplastic fibroma of the mandible

Desmoplastic fibromas of the facial skeleton are the bony counterparts to the soft-tissue desmoid tumors and are almost exclusively confined to the mandible. The diagnosis should be considered whenever a rapidly increasing swelling with little functional disability is noted in the mandible. Historical, clinical, radiologic, and histologic findings must be correlated to establish the correct diagnosis. Every effort must be made to distinguish these lesions from well-differentiated fibrosarcomas. An illustrative case is presented. The treatment of desmoplastic fibromas affecting the facial skeleton should be conservative. Curettage is recommended for small tumors. Wide resections with reconstruction should be reserved for larger lesions and for those that have recurred after conservative treatment.     

Rupture of the round window membrane (author's transl)]

Labyrinthine fistula of the round window should be considered in the differential diagnosis of vertigo and sudden hearing loss occurring in patients, who are not only divers, during physical stress or exertion. Surgical exploration and closure of the fistulae are the only means of diagnosis and treatment of this condition. Since these fistulae may heal spontaneously in most instances early surgery is recommended after a short interval of conservative therapy. Five patients, of whom 4 underwent surgery and one was seen for an expert opinion are presented.     

Osteonecrosis of the jaws by long term therapy with bisphosphonates]

For several decades bisphosphonates have been used to reduce skeletal related events in patients with both osteoporosis or bone metastases. Under long term application, besides the known therapy side effects, a new clinical picture has been described within the last few years. This is osteonecrosis of the jaws, which is characterized by its difficulty in treatment. Besides exposed jaw bone, the start of the disease usually lacks any symptoms. The typical clinical symptoms then are foetor ex ore, swelling, exsudation, loosening of teeth, pain or paresthesia. Later oro-antral/nasal or oro-cutaneous fistula can develop. The X-ray shows persisting tooth sockets after extractions and later cloudy radio-lucency, sequestra or fractures. The patient exposed to bisphosphonate can be grouped according to the risk for osteonecrosis: high risk patients with intravenous bisphosphonate therapy and additional chemo-, radiation or corticoid therapy--predominantly patients with a malignant underlying disease and bone metastases low risk patients with an oral bisphosphonate therapy without additional chemo-, radiation or corticoid therapy--preferably patients with non-corticoid-induced osteoporosis. Before starting a bisphosphonate therapy possible causes of infection should be treated and risk of injuries to the mucosa should be reduced according to the individual risk profile. This is supplemented by information of the patient about the risk of necrosis and the possibilities for prevention. Regular dental recall under bisphophonate therapy is emphasised for early recognition of possible problems. Prophylaxis is recommended for the prevention of periodontal infection combined with a follow up of removable denture for possible ulcera. Generally, conservative treatment measures are preferred to surgical ones. Inevitable operations are carried out non-traumatically using broad spectrum antibiotic prophylaxis until the day of suture removal (not before day 10). Long term follow up examinations are recommended.Patients with dental implants inserted before a bisphophonate therapy should be subject to intensive recall examinations. For patients undergoing or following a bisphosphonate therapy the indication for dental implants should be as strict as for patients following head and neck radiation therapy. In the present for patients with osteonecrosis, even after healing, dental implants are regarded as contra-indication. Therapy of the necrosis often requires general anaesthesia, hospitalisation, naso-gastral feeding tube and intravenous, systemic antiinfective treatment. The necrosis is removed completely and a tension free wound closure with vascularised tissue is intended. A literature review shows the metabolic effect of biphosphonates, the known pathogenesis of the bisphosphonate-induced jaw necrosis. It is essential to develop interdisciplinary communication, aiming at a joint care for this group of concerned patients and involving not only those medical disciplines, which order and use bisphosphonates, but especially dentists and maxillofacial surgeons.     

Etiology and treatment of fluid retention (hydrops) in Ménière's syndrome.

For years low sodium diets have been recommended in the treatment of Ménière's syndrome. Elevated levels of insulin play an important role in sodium retention in renal tubules. Insulin production is stimulated by high carbohydrate diets. Adrenaline, cortisone, and glucagon levels may be increased by stress or food or inhalant allergies, further elevating insulin levels. The end result of prolonged hyperinsulinemia includes vasoconstriction and eventually arterial smooth muscle hypertrophy. Individual susceptibility to Ménière's syndrome may occur as a result of inflammatory changes in the endolymphatic sac or cochlear aqueduct secondary to primary or latent viral infections, thus predisposing to fluid retention. Long term medical treatment of Ménière's should be directed towards preventing sodium retention through sodium restriction and carbohydrate management. Other factors including stress and allergy should also be considered.     

Posterior table fractures of the frontal sinus: Ii. Clinical aspects

The evaluation of fractures involving the frontal sinus is important since significant complications can occur acutely or many years following injury. Thorough roentgenographic analysis, with special emphasis on the status of the nasofrontal duct, is required. The extent of soft tissue injury cannot be used as a guide. Furthermore, the proper treatment of fractures involving the posterior table has been controversial. In general, all fractures of the posterior table should be explored. Complete neurological evaluation is necessary and an observation period of approximately 48 hours is recommended prior to surgery. A coronal incision is suggested since a craniotomy can be performed with the exposure obtained. In selected patients, conservative treatment may be warranted but close follow-up with serial X-rays is necessary. Primary adipose obliteration of the injured sinus is recommended as treatment since complications are eliminated by a single operation which is cosmetically acceptable. This is supported by existing clinical series and experimental evidence. Adipose tissue possesses certain advantages which make it the tissue of choice for obliteration. Infection involving the implanted fat does not appear to be a significant problem. Bony fragments of the posterior table may safely be left in place. Dural lacerations occurring immediately behind the posterior table can be managed through the sinus without the necessity of craniotomy.     

Actualización del consenso sobre el diagnóstico y tratamiento de la sordera súbita idiopática

IntroductionIdiopathic sudden sensorineural hearing loss (ISSNHL) is a sudden, unexplained unilateral hearing loss.ObjectivesTo update the Spanish Consensus on the diagnosis, treatment and follow-up of ISSNHL.Material and methodsAfter a systematic review of the literature from 1966 to March 2018, on MESH terms «(acute or sudden) hearing loss or deafness», a third update was performed, including 1508 relevant papers.ResultsRegarding diagnosis, 11 ISSNHL is clinically suspected, the following diagnostic tests are mandatory: otoscopy, acumetry, tonal audiometry, speech audiometry, and tympanometry, to discount conductive causes. After clinical diagnosis has been established, and before treatment is started, a full analysis should be performed. An MRI should then be requested, ideally performed during the first 15 days after diagnosis, to discount specific causes and to help to understand the physiopathological mechanisms in each case. Although treatment is very controversial, due to its effect on quality of life after ISSNHL and the few rare adverse effects associated with short-term steroid treatment, this consensus recommends that all patients should be treated with steroids, orally and/or intratympanically, depending on each patient. In the event of failure of systemic steroids, intratympanic rescue is also recommended. Follow-up should be at day 7, and after 12 months.ConclusionBy consensus, results after treatment should be reported as absolute decibels recovered in pure tonal audiometry and as improvement in speech audiometry.     

Conservative management of acoustic neuromas.

The results of this study and others document the biologic behavior of acoustic neuromas. In view of the evidence presented, which describes both variable rates of individual tumor growth and spontaneous regression in size, it would seem prudent that before selecting a nonsurgical treatment modality, the growth rate for the particular tumor in question should be established. To date, none of the literature that addresses the use of focused irradiation has attempted to do so. Our study as well as those of others suggests that the growth rate of acoustic neuromas becomes predictable over time. Based on this observation, a conservative (nontumor excision) management strategy is proposed for selected individuals. Patients to whom this management philosophy has been recommended or who themselves have chosen this option are seen twice yearly. Each visit consists of a thorough neurotologic examination as well as high-definition CT or MRI. Careful comparison of the clinical course as well as calculation of the tumor size is carried out in each instance. If the clinical course and rate of tumor growth remain unchanged over a 3-year follow-up, annual assessments are recommended. In the event of tumor enlargement, surgery may or may not be recommended, depending on the rate of growth and the age of the patient. Our experience suggests that a rate of growth equal to or exceeding 0.2 cm per year constitutes an indication for tumor removal.     

Supportive therapy in medical therapy of head and neck tumors

Fever during neutropenia may be a symptom of severe life threatening infection, which must be treated immediately with antibiotics. If signs of infection persist, therapy must be modified. Diagnostic measures should not delay treatment. If the risk of febrile neutropenia after chemotherapy is ≥ 20%, then prophylactic therapy with G-CSF is standard of care. After protocols with a risk of febrile neutropenia of 10-20%, G-CSF is necessary, in patients older than 65 years or with severe comorbidity, open wounds, reduced general condition. Anemia in cancer patients must be diagnosed carefully, even preoperatively. Transfusions of red blood cells are indicated in Hb levels below 7-8 g/dl. Erythropoiesis stimulating agents (ESA) are recommended after chemotherapy only when hemoglobin levels are below 11 g/dl. The Hb-level must not be increased above 12 g/dl. Anemia with functional iron deficiency (transferrin saturation < 20%) should be treated with intravenous iron, as oral iron is ineffective being not absorbed. Therapy of pain must follow diagnostic and treatment standards. Nausea or emesis following chemotherapy can be classified as minimal, low, moderate and high. The antiemetic prophylaxis should be escalated accordingly. In chemotherapy with low emetogenic potential steroids are sufficient, in the moderate level 5-HT3 receptor antagonists (setrons) are added, and in the highest level Aprepitant as third drug.     

Die Globussensation

Globus sensation is a medially felt lump in the throat. It can be associated with a number of different diseases, but this symptom may also occur monosymptomatically as a somatoform disorder or as a secondary somatoform illness behavior. Globus sensation may be persistent or intermittent. Diagnosis requires close interdisciplinary cooperation, since the globus may be a symptom of anxiety, depression or personality disorders. Firstly, patients should undergo a thorough otolaryngological examination (including careful medical history taking), possibly in cooperation with other medical specialists. Subsequent psychosomatic and clinical tests – if necessary – may be time-consuming due to complex interrelations between somatic vulnerability and psychosocial coping strategies. Sometimes a comorbid disorder is diagnosed and the primary disease treated; however, the identification of multiple etiologically effective mechanisms is impossible. If the patient is unable to accept his benign monosymptomatic globus as a somatoform disorder (ICD-10; F45.8), a combination of pharmacologic intervention and cognitive-behavioral intervention as an integrated treatment approach is recommended. However, the symptom has a strong tendency to recur. Since controlled therapy studies are scant to date, evidence-based treatment concepts are currently not available.     

The management of glomus jugulare tumours

The treatment details of 58 patients treated for glomus jugulare tumours in Newcastle upon Tyne are examined in the light of other studies reported in the literature. For the group of 55 patients treated by radiotherapy, the 20 year survival is 94% (determined actuarially). The 20 year disease-free survival (determined actuarially) is 77%. This is comparable with other series reported. As no glomus tympanicum tumour has recurred following surgery and there has been no morbidity due to these tumours they have not been included in the series. It is recommended that patients who are fit and have tumours confined to the tympanum should have primary surgical treatment. All other patients should be treated by accurately planned radiotherapy, using a dose of 50Gy in 5 weeks to the tumour volume. The morbidity of this treatment policy will be low.     

Guidelines of the French Society of Otorhinolaryngology–Head and Neck Surgery (SFORL), part I: Primary treatment of pleomorphic adenoma

IntroductionThe authors present the guidelines of the French Society of Otorhinolaryngology–Head and Neck Surgery (SFORL) for the diagnosis and treatment of pleomorphic adenoma (PA) of the salivary glands.MethodA review of the literature was performed by a multidisciplinary task force. Guidelines were drafted based on the articles retrieved and the workgroup members’ individual experience. Guidelines were graded A, B, C or expert opinion by decreasing level of evidence.ResultsIn clinically suspected salivary gland PA, MRI should be performed, including head and neck lymph node levels. Fine needle aspiration cytology is particularly recommended for tumours difficult to characterise by MRI. Frozen section biopsy should be performed to confirm diagnosis and adapt the surgical procedure in case of intraoperative findings of malignancy. Complete resection of the parotid PA should be performed en bloc, including margins, when feasible according to tumour location, while respecting the facial nerve. Enucleation (resection only in contact with the tumour) is not recommended. For the accessory salivary and submandibular glands, complete en bloc resection should be performed.     

Treatment alternatives for chronic rhinosinusitis persisting after ESS: what to do when antibiotics, steroids and surgery fail

BACKGROUND: It is estimated that over 500,000 individuals in the United States currently suffer from chronic rhinosinusitis (CRS), which has persisted or recurred despite maximal medical therapy and endoscopic sinus surgery (ESS). Management of these individuals remains uncertain, as recent published guidelines on CRS do not extend to this population. OBJECTIVE: Our objective is to provide a framework for the management of patients who fail standard therapy for CRS while providing recommendations based on the strength of the evidence for alternative medical therapies that can be used for the treatment of recurrent CRS. This guideline targets ENT physicians and allergists managing this increasingly frequent clinical situation and attempts to assist them in selecting from the increasing array of potential therapies available. To this end, factors contributing to the pathophysiology of post-ESS CRS are reviewed to identify method of action of existing and potential therapies and recommendations are made for their use. RESULTS: Given the accessibility of the sinus cavities after ESS, topical therapies are privileged. Saline spray or irrigation is recommended for all patients. Corticosteroids in oral or topical forms are recommended for controlling the inflammatory component, while the use of a short term course of oral or topical antibiotics are recommended mainly for the treatment of exacerbations. Long-term therapy with oral macrolides is also recommended as an alternative therapy. Desensitization with acetylsalicylic acid (ASA) for individuals with documented ASA sensitivity is recommended where available, while revision surgery, anti-leukotriene agents and intravenous immunoglobulins are options in management in selected patients. Antifungal therapy is not recommended. No recommendations for potentially experimental strategies are made in the absence of published experience and safety data in human subjects.     

Surgical treatment of the neck in cancer of the larynx

Current concepts in management of the clinically negative and clinically positive neck in laryngeal cancer are reviewed. Occult disease in the neck not detected by physical and radiographic examination may also be difficult to identify on routine histologic examination. Immunohistochemistry or molecular analysis may detect metastatic involvement not apparent by light microscopy. The surgeon should be aware of the relatively high incidence of micrometastases in patients with laryngeal cancer to establish optimal treatment approaches. Elective treatment of the neck is recommended for supraglottic tumors staged T2 or higher, and glottic or subglottic tumors staged T3 or higher. The neck may be treated electively by either surgery or irradiation, but irradiation is best reserved for cases where that modality is employed for the primary tumor. Elective neck dissection provides important information for prognostic purposes and therapeutic decisions, by establishing the presence, number, location and nature of occult lymph node metastases. The selective lateral neck dissection (levels II, III and IV), unilateral or bilateral, is the procedure of choice for elective treatment. Paratracheal nodes (level VI) should be dissected in cases of advanced glottic and subglottic cancer. Complete radical or functional neck dissections are excessive in extent, as levels I and V are almost never involved. Sentinel lymph node biopsy may fail to detect tumor on frozen section examination or may not reveal 'skip' metastases. The clinically involved neck is usually treated by complete radical or functional neck dissection of levels I through V. Selective neck dissection has been employed successfully in selected cases, particularly for N1 or occasionally N2 nodal involvement. The selective neck dissection can be extended to include structures at risk. More advanced disease has been treated in this manner often in association with adjuvant chemotherapy and/or irradiation. While the benefit of adjuvant treatment is difficult to assess, it appears most useful in cases with extranodal spread of disease, a factor associated with the worst prognosis.