Nachblutungen und Gerinnungsst?rungen bei Tonsillektomien

Background

The aim of our prospective analysis was to show the incidence of bleeding disorders among a tonsillectomy patient population and in case of bleeding disorders.

Patients and methods

This study comprised 92?consecutive patients who underwent tonsillectomies from 1 January 2007 to 31 December 2007 at the Department of Otorhinolaryngology, University Medical Center Mainz. In addition to gender, age, date of bleeding, Quick, aPTT and platelet count, the following blood values were determined: vWF:AG, vWF:RCo, vWF:RCo/vWF:AG, factor XIII, factor VIII:C, PFA 100? ADP and PFA 100? epinephrine (special coagulation analysis).

Results

Twelve of 92?patients (13%) showed evidence of coagulopathy. Four of these 12?patients had a postoperative hemorrhage. In eight?patients a factor XIII deficiency was diagnosed, with two of them suffering a hemorrhage. In four?patients, von Willebrand disease was diagnosed; two of them bled. No correlation between the presence of a coagulopathy and the bleeding rate could be determined.

Conclusion

Routine preoperative performance of special coagulation analysis in all patients does not significantly contribute to the detection of increased postoperative hemorrhage risk.     

Coblation-Tonsillektomie

Background

The introduction of coblation tonsillectomy (CTE) may contribute to reduce the postoperative morbidity in terms of pain, delayed oral intake and bleeding.

Methods

A prospective pilot study was undertaken to evaluate the clinical course by inpatient observation (5 days) and telephone contact 6 months after CTE. The data from 61 patients (aged 44 months–69 years) were analyzed. The patients were grouped into those with surgical care of bleeding (A), non-surgical care of bleeding (B), and no bleeding event (C).

Results

The study was terminated early due to major bleeding complications in seven patients (A). Fifteen patients experienced minor (B) and 41 no (C) bleeding episodes. In the interview, 29 patients identified pain, lasting 16.7 (A), 11.6 (B) and 11 (C) days, as the most significant complication of surgery.

Conclusions

The introduction of CTE was followed by a dramatic increase in major bleeding complications, including late bleeding episodes. Pain following tonsillectomy remains a problem to be solved by further techniques. We will continue to perform the cold dissection technique.     

Die Anwendung des Appropriateness Evaluation Protocol bei HNO-stationärem Patientengut

Background and objective: Determination of inappropriate hospital use is of increasing importance due to limited resources in health care. The Appropriateness Evaluation Protocol (AEP) serves as an instrument to identify this inappropriate hospital use. It was designed in the USA in 1981 for use in Internal Medicine and General Surgery and consists of criteria items to assess the appropriateness of hospital admissions and days of care. Patients/Methods: The present study aims to examine the practicability of the AEP in Otorhinolaryngology. The charts of all patients hospitalized in the ENT Department at that particular day were surveyed on 4 consecutive Wednesdays. Three reviewers each reviewed 196 charts. Results: The overall level of inappropriate use was 41.5%. Presuming that the day preoperative to elective surgery was appropriate, the level was 23.1%. Conclusions: The critical comparison between this result and the actual reasons for hospital admissions and days of care showed, that the present German version of the AEP is less suitable for use in Otorhinolaryngology. Based on the experiences with the AEP an AEP adjusted to Otorhinolaryngology (AEP-ENT) is proposed.     

Tonsillektomie mit Koagulationsschere oder Raspatorium

Background

Postoperative bleeding is the major complication in tonsillectomy, and pain the most common side effect. The use of bipolar scissors versus blunt dissection tonsillectomy were compared in this study in order to evaluate postoperative bleeding and pain, as well as operative time.

Methods

In this case control study, 138 patients with the diagnosis of chronic tonsillitis, mononucleosis or a peritonsillar abscess were divided into two groups. A total of 78 patients were operated using bipolar scissors while 60 patients underwent tonsillectomy by blunt dissection. Operating time, frequency of postoperative bleeding and the postoperative pain score were compared between these two groups.

Results

The average operating time in the bipolar scissor group showed a tendency to be shorter than in the blunt dissection group (mean 4.1 min), although this did not reach a level of statistical significance. No differences were seen in pain scores or in the incidence of postoperative bleeding.

Conclusion

The data documented in this study show that tonsillectomy with bipolar scissors might represent a surgical option to reduce surgical time in a larger patient group. Postoperative pain and the incidence of postoperative bleeding did not show any statistical difference between the two surgical techniques.     

Tonsillectomy in adults: Analysis of indications and complications

Objective

Tonsillectomy is one of the surgical techniques most practiced by otolaryngologists, and despite being a relatively simple technique; it presents a considerable percentage of complications, such as postoperative bleeding. The aim of this study is to describe the surgical indications and most frequent complications, analyze whether surgical suture of the tonsillar pillars has an influence on bleeding, and study the data of hospital stay and its importance for the control of complications.

Gelatine-Thrombin-Matrix zur Blutstillung

Background

To assess the feasibility of omitting thermal coagulation following cold knife tonsillectomy, we compared the use of a local thrombin hemostat (FloSeal®, FS) to bipolar electrocautery (EK).

Patients and methods

A total of 181 patients with chronic tonsillitis or tonsillar hypertrophy were stratified in terms of patient characteristics and randomized before undergoing tonsillectomy. The follow-up period continued until postoperative day 20.

Results

FS-treated patients reported lower postoperative pain intensity scores (p?=?0.011) and significantly reduced pain duration (p?<?0.001). Whilst wound healing appeared to be improved in FS patients, the rates of postoperative hemorrhage remained unchanged. Use of an FS enabled inexperienced surgeons (<?100 procedures) to reduce their operating time by 8 min (p?=?0.05), although no effect was observed for experienced surgeons.

Conclusion

Hemostasis is effectively mediated by an FS and its application reduces postoperative pain intensity and duration. Although we observed accelerated wound healing and reduced operating times owing to a more calculable rate of hemostasis, this did not influence the rates of postoperative hemorrhage.     

Spontaneous defects of the lateral cranial base. 1. Clinical aspects,diagnosis and therapy

Background. Spontaneous cerebrospinal fluid otorrhea (SCFO) or rhinorrhea originating from laterobasal defects is uncommon. An immediate closure of the defect is mandatory due to the risk of life-threatening meningitis. The purpose of this paper is to review the literature and to present two additional case reports with emphasis on diagnostic problems and surgical techniques. Patients and methods. Two adults have been treated for SCFO in our clinic. A 62-year-old woman was complaining of pertinent otorrhea after placement of a ventilation tube and conservative treatment of serous otitis for 1 year elsewhere. A 66-year-old male patient had been treated for acute pneumococcal meningitis. He presented with unilateral deafness and vertigo 3 months later. High-Resolution-Computer-Tomography (HRCT) revealed a unilateral defect in the female and a bilateral defect in the male patient. A transmastoidal approach was used to amputate the meningoencephalocele and modified (Mini-Craniotomy) in the second (male) patient. The defect was closed in two layers using allogenic material and fibrin glue. Results. One year after surgery both patients were free of symptoms and defect closure remained stable in HRCT and under microscopic view. Conclusions. SCFO from tegmen defects is an uncommon cause of otorrhea and even rhinorrhea. History and clinical presentation of our patients can be regarded as typical for adults with SCFO. Evaluation of history, HRCT and a high index of suspicion is a prerequisite for correct diagnosis. The approach (trans-mastoidal, transtemporal, Mini-Craniotomy) to repair leaks of the tegmen should be related to the extent of the defect.     

Nachblutungsrate nach Coblation-Tonsillektomie

Background

With over 100,000 cases annually, tonsillectomy is one of the most frequently performed ENT surgical procedures in Germany. Hemorrhage ranks among its serious postoperative complications. In this systematic review, we analyze hemorrhage following tonsillectomies performed using coblation technique.

Methods

Of the 135 studies identified, 38 could be included in the analysis, most being prospective randomized controlled studies. Data from 6290 patients were gathered.

Results

Of all tonsillectomies performed, hemorrhages occurred in 355 patients. Of these, 256 cases could be classified as 41 primary and 215 secondary hemorrhages. Overall, the total hemorrhage rate for the coblation procedure was 4.9% (95%-CI: 0.044–0.054) for the fixed effects model.

Conclusion

Significantly higher rates of postoperative hemorrhage were found in a few studies, yet they were well above the 95% confidence interval of 4.4–5.4% of the literature. These studies could possibly be interpreted in terms of an autodidactic learning process. As with any surgical technique, proper training is essential.     

Rheologische Infusionstherapie, Neurotransmitterapplikation und Lidocain-Injektion bei Tinnitus Ein therapeutisches Stufenkonzept

Background and objective. Cochlear dysfunction and tinnitus are treated by means of hemorrheological infusions in order to increase the cochlear oxygen supply and restore function of hair cells, neurotransmission and central processing of auditory information. Patients/methods. In a retrospective analysis of the charts of 123 patients treated between February 1993 and May 1994, we analyzed effectiveness and safety of a gradual therapeutic regimen, consisting of dextrane/procaine infusions, lidocaine i.v. injection and infusion therapy with the neurotransmitter glutamic acid. Results. Tinnitus decreased in 83.7% of patients with acute tinnitus (AT) and 16.1% of patients with chronic tinnitus (CT) during dextrane/procaine infusion. The majority (89%) experienced their tinnitus relief during the first 5 days. Treatment with glutamic diethylester and glutamic acid resulted in a 26.5% overall improvement. Application of lidocaine intravenously over a period of 10 min diminished tinnitus loudness or frequency in 16.7% (AT) and 38.9% (CT) of cases respectively. The long-term effects of therapy were investigated by a follow-up mailing action: 66.7% of the AT and 15.6% of the CT sufferers stated a clear therapy effect over time. Nonserious side effects were noted in 4% of the treated patients. Therefore safety was excellent. Conclusions. For acute and chronic tinnitus a gradual therapeutic regimen is recommended: (1) infusions with dextrane and procaine over 5 days; (2) intravenous application of 100 mg lidocaine over 10 min; and if necessary (3) administration of glutamic diethylester and glutamic acid for 3 days. This resulted in overall tinnitus relief in 95.3% of the acute and 26.7% of the chronic tinnitus sufferers.     

Fantoni translaryngeal tracheotomy (TLT) with rigid endoscopic control

Rationale. The incidence of translaryngeal tracheotomy (TLT)-associated peri- and postoperative complications should be assessed prospectively. Methods. TLT was carried out in operation-theatre under rigid endoscopic control. Peri- and postoperative complications, decanulement and late sequelae were assessed in ENT-patients. In patients of other wards only perioperative complications were evaluated. Results. 41 patients (26 ENT-patients, 15 patients of other wards) were tracheotomised by TLT. Perioperatively, we observed 3 technical problems (accidental pulling through of the tracheostomy tube). In 2 of these cases TLT could be completed without problems, in 1 case TLT was converted to surgical tracheotomy. Postoperatively, we could find no complications in 26 ENT-patients. Decanulation took place after 7 days on average. We found no tracheocutaneous fistulas or tracheostenoses, scars were unobtrusive. Conclusions. TLT with rigid endoscopy is a simple percutaneous tracheotomy-technique with a low complication rate.     

Risiko von Blutungen nach Adenotomie und Tonsillektomie

Background

Hemorrhage after tonsillectomy and adenoidectomy remains a serious complication. Therefore, routine preoperative coagulation screening, including activated partial thromboplastin time (aPTT), prothrombin time (PT) and platelet count (PLC), are regularly performed, also for medicolegal reasons. In the recently published statement of the German Society of Otorhinolaryngology, Head and Neck Surgery the need for routine preoperative coagulation screening is discussed, but so far no standardized procedure had been established. According to this statement – at least for children – routine preoperative coagulation screening is not mandatory as long as the thorough medical history provides no evidence for a coagulation disorder (http://www.hno.org/kollegen/gerinnung_te_ae.html). The present study was undertaken to determine the occurrence of postoperative hemorrhage on the one hand, and the incidence of abnormal preoperative routine coagulation parameters or pathological anamnesis findings on the other.

Patients and Methods

In 688 patients, a standardized clinical history was obtained using a questionnaire. Coagulation screening included aPTT, PT, and PLC was also carried out. Bleeding complications were then correlated with anamnesis features and abnormalities in coagulation screening.

Results

In 39 (5.7%) of the 688 patients we found abnormal coagulation values, which were confirmed in repeated analyses. In six of these a detailed analysis revealed occult coagulation disorders requiring correction only in the case of bleeding complications who were previously unknown. Fifteen patients were already known to have a coagulation disorder, and the anamnesis identified no additional patient at risk. Thus, 21 patients with coagulation disorders requiring correction in the case of a bleeding complication underwent surgery. However, only eight (38%) of these showed abnormal routine coagulation parameters. Surgical treatment of postoperative hemorrhage was required in 12 patients, all of whom had normal values for aPTT, PT and PLC.

Conclusion

The frequently performed determination of routine coagulation parameters (aPTT, PT, PLC) is not able to reliably identify relevant coagulation disorders or to predict the risk for postoperative hemorrhagic complications after adenoidectomy or tonsillectomy.     

A concept for the assessment of quality of life in patients with carcinomas of the upper aerodigestive tract

Background. The quality of life (QoL) of patients with malignant diseases decreases significantly. Objective. The evaluation of QoL is generally not part of the management of patients with head and neck cancer. The aim of this study was to develop an additional disease- and treatment-specific questionnaire to evaluate QoL in surgically treated head and neck cancer patients. Patients and methods. The general QoL was evaluated with the QLQ-C30 questionnaire developed by the European Organisation of Research and Treatment of Cancer (EORTC). Results. The disease-specific QoL was evaluated using the EORTC H&;N35 module. The new questionnaire “Kiel Head and Neck 17” (KQL H&;N-17) is a disease- and treatment-specific addition especially in regard to side effects caused by surgical treatment. Conclusions. A wide application of this whole concept is needed to obtain comparable results from studies suitable for evaluating QoL in patients receiving different treatments for their malignant diseases. Moreover, the effectiveness and quality of treatment could be controlled better, which would help to increase the QoL of these patients.     

Validierung einer automatischen Analyse der Sprechproben von Kindern mit isolierter Gaumenspalte

Background

Following surgical repair of cleft lip and palate, hearing and speech and language development are important issues for the continued care of affected childhood and adolescent patients. Therefore, PEAKS (Program for Evaluation and Analysis of all Kinds of Speech Disorders) was developed in order to rate speech intelligibility automatically and reduce the time required for diagnostics. PEAKS is based on a speech recognition system and was extended to incorporate a speaker model. This investigation validated PEAKS for isolated cleft palate.

Methods

From each of the 39 children with isolated cleft palate (3.1–14.5years), 99 word productions were recorded digitally and analyzed—once “subjectively” by five experts and five nonexperts; once “objectively” using PEAKS.

Results

The automatic speech recognition system and the experts arrive at similar results with regard to speech intelligibility. The expert and nonexpert ratings differ significantly from each other. Within the group of nonexperts, a weak interrater reliability demonstrates the uncertainty associated with their ratings.

Conclusion

PEAKS delivers reliable and representative results with regard to speech intelligibility among children and adolescents with isolated cleft palate. The automatic measurement of speech quality in children and adolescents with isolated cleft palate is possible.     

Operative Behandlung des differenzierten Schilddrüsenkarzinoms Technik und Morbidität der paratrachealen Lymphadenektomie

Background. The extent of cervical lymphadenectomy in treatment of differentiated thyroid cancer is controversial. Technique and results of paratracheal lymphadenectomy are presented to demonstrate safety of cervical lymphadenectomy procedures. Patients and methods. 68 Patients with differentiated thyroid cancer underwent total thyroidectomy and extended lymphadenectomy in a standardized technique. The pre- and paratracheal and the lateral lymphnode compartments were cleared. Results. Permanent pareses of recurrent laryngeal nerve or permanent hypocalcaemias were not observed. 3 patients developed transient recurrent nerve palsy, 26 patients transient hypocalcaemia (Ca²⁺ >1,7 and <2,2 mmol/l). In 3 patients mild voice disturbances, probably due to superior laryngeal nerve dysfunction were observed. In 1 patient shorttime tracheotomy was performed. 1 patients showed permanent Horner's syndrome. Conclusions. Thyroidectomy with extended lymphadenectomy achieves removal of all cervical tumor masses without relevant morbidity. The distribution of metastatic lymph nodes underlines the necessity of extended lymphadenectomy.     

Inzidenz von Speichelfisteln in Abhängigkeit vom Zeitpunkt einer oralen Ernährung nach Laryngektomie

Background and objective. A pharyngocutaneous fistula is the most common complication after total laryngectomy. In Germany, a traditional recommendation is to use a nasogastric tube for feeding for 10–14 days postoperatively because many surgeons believe that oral feeding after surgery contributes to fistula development. However, there is no international agreement about when to begin oral feeding after total laryngectomy. Some authors begin oral feeding between the 1st and 4th postoperative day without any nasogastric tube, while others using a nasogastric tube delay oral feedings until 7–14 days after surgery. The aim of the present study was to investigate the relationship between the timing of oral feeding and the development of fistulas after total laryngectomy. Patients/methods. In a prospective trial with 42 consecutive patients who underwent laryngectomy, oral feeding was started on different postoperative days between the 1st and the 10th. Most patients were selected randomly for the different postoperative days. Furthermore, other potential risk factors predisposing to fistula formation were analyzed retrospectively. Results. Five fistulas occurred in the total group (12%). Early postoperative oral feeding does not increase the incidence of fistulas. The fistula rate was only 9% in patients fed orally in the 1st postoperative week. The analysis of further risk factors for fistula formation showed only a significant correlation between type of resection and fistula occurrence (extended laryngectomy with partial pharyngectomy vs standard laryngectomy; p = 0.018). Conclusions. Our results indicate that early oral feeding in the 1st postoperative week does not influence fistula formation after laryngectomy.     

Behandlung der therapieresistenten chronischen Otitis externa durch lokale Injektion von Triamcinolonacetat-Kristallsuspension Erste Erfahrungen

Background and objective. External otitis is characterized by otalgia, otorrhea, itching, and hearing loss. Treatment usually consists of local application of corticosteroids and antibiotics. Chronic external otitis is accompanied by thickening of the skin in the external auditory channel. This reduces the effect of the applied substances. Local injection of suitable drugs may support the conservative treatment. The aim of the study was to evaluate the efficacy of local injection of triamcinolone acetonide in the external auditory channel. Patients/methods. Thirteen patients with external otitis resistant to conservative treatment received an injection of triamcinolone acetonide in the external auditory channel. The improvement achieved was assessed by clinical examination and questionnaires. Results. The symptoms improved substantially in all patients; most of the patients were cured completely. Conclusions. Our results demonstrate that local injection of triamcinolone acetonide is effective in the management of chronic external otitis.     

Endotracheale Silikonstents im Therapiemanagement benigner Trachealstenosen Ergebnisse nach 5-jähriger Anwendung

Background. Advances in endoscopic technique and the development of new materials have made stenting an interesting alternative to surgical treatment for extended tracheal stenoses. This 5 years' retrospective study describes long term results of silicon stents in patients with benign chronic tracheal stenoses. Patients and methods. 45 adult patients (mean age: 45 years) had endotracheal Dumon (Endoxane) stent placement as surgical therapy was not indicated. Fiberoptic controls were performed every 3–6 months. Results. In 42 patients therapy proved successful with improved ventilation and high level of tolerance. Acut stent-removal was necessary in 2 patients because of edema of the vocal cords, in 1 patient because of stent independent paralysis of both recurrentes nerves. Further complications included migration (16,6%), granuloma formation (33,3%) and airway obstruction due to heavy secretion (2,3%). Conclusions. Long term results have shown that this technique is associated with high efficiency and infrequent complications which are not life-threatening. Advantages consist in a minor-invasive technique with small expenditure of time.     

Reconstruction after extended partial laryngeal and hypopharyngeal resections. A new method with rib cartilage,chondrosynthesis and free radial transplants

Partial pharyngectomy combined with subtotal laryngectomy results in permanent tracheostomy and long lasting swallowing difficulties in many cases. Based on our prior experimental and clinical studies on laryngeal chondrosynthesis the objectives of this project were to develop a method for reconstruction of up to two thirds of the larynx and one pyriform sinus. Method. The resected laryngeal framework is reconstructed with autogenous rib cartilage and stabilized with plates and screws. In addition a piece of cartilage is used as a buttress for apposition by the remaining mobile vocal cord. A free radial forearm flap covers the reconstructed framework and forms the sulcus of the pyriform sinus. Results. Up to now 7 patients have been operated with this technique. The follow up was 35 months on average. None of the patients has a clinically relevant aspiration. All patients have a well understandable voice and one of them – a teacher – could even resume his speech profession. Conclusion. In selected patients these techniques enable functional rehabilitation of swallowing, breathing and speech even after extended partial pharyngolaryngectomy.     

Bilateral bone anchored hearing aid management of children with external ear dysplasia and/or ear canal atresia

Background and objective. The literature gives hardly any information about the benefits for children of using a bilateral bone-anchored hearing aid (BAHA) as opposed to a bilateral conventional bone conducting hearing aid. Patients and methods. Within a period of 12 years, three children were selected for treatment with bilateral BAHA. At the time of surgery, the children were aged between 8 and 10 years. Two of the children suffered from Franceschetti syndrome and one child from Goldenhar's syndrome. The clinical course of these three patients is presented. Results. In all cases, treatment with BAHA was beneficial according to subjective and objective criteria despite localized inflammatory complications in two of the three cases. Conclusions. The bilateral use of BAHA should be considered more frequently as an alternative to conventional bone conducting hearing aids even for children.     

Hemmung zellulärer SignaltransduktionskaskadenEine zukünftige antiinvasive Therapiestrategie für Karzinome in der Kopf- und Halsregion

Background. Squamous cell carcinomas of the head and neck are considered to be highly aggressive cancers. The 5-year survival rate of patients with this disease depends on whether a locoregional relapse occurs and if so, how early after the initial treatment. Disease was found to relapse more frequently in patients suffering from cancers with an invasive growth pattern. It was therefore concluded that cancer cell invasion influences the patient's survival. While considerable efforts are made to develop treatment regimens for relapsing disease, a novel approach consists of the prevention of the disease recurrence through the inhibition of cancer cell invasion. Method. Literature search. Results. We summarize in this article the mechanisms of tumor invasion, focusing on the regulation of tumor proteases, which are essential for cancer invasion, and provide an overview of preliminary results with novel anti-invasive treatment strategies. Conclusion. Novel anti-invasive treatment regimens based on an understanding of molecular cancer invasion mechanisms may be used in the future to treat patients with head and neck cancers.