Berechenbare Nahttechniken für die Nasenspitze bei Rhinoplastik

Recontouring the nasal tip in rhinoplastic procedures has generated a wide range of surgical techniques. These range from aggressive cartilage resection, division, grafting, or suture methods. Each of these categories contains many variations described in hundreds of publications. The goal of this communication is to describe a predictable, reproducible technique that can be used in a wide variety of rhinoplasty operations. Based on pre-existing anatomy variations of this technique can be adopted. The author described the basic technique in 2004 [1]. The cornerstone of the technique is a predictable method of narrowing the interdomal space utilizing a suture technique. This procedure employs a pair of permanent sutures designed to minimize distortion, valve impingement and overcorrection. It can be performed through intranasal or external approaches. This paper will define the wide interdomal space, describe the technique, and demonstrate the efficacy of the technique in 250 rhinoplasty procedures. In addition, variations of the technique for specific goals will be shown.     

The Tympanic Isthmus: Its Anatomy And Clinical Significance

The tympanic isthmus is a narrow passage between the tubotympanic cavity and the atticomastoid air space. Obstruction of the tympanic isthmus is frequent in various types of middle ear disease and causes significant air-diffusion disturbance within the temporal bone pneumatic system. Using large numbers of fresh temporal bone specimens, anatomical boundaries of the tympanic isthmus are defined and pathological variations are investigated. Embryological origin of the isthmus and pathophysiological implications of the tyrnpanic isthmus block are discussed. Among factors that cause obstruction of the tympanic isthmus are mucosal folds variations, inflammatory webs and exudate, retracted tympanic membrane, diseased attic mucosa, and cholesteatoma. Each factor is analyzed with representative specimen photographs. Clinical signs due to tympanic isthmus block often simulate or coexist with symptoms of eustachian tube obstruction. Surgical management of the tympanic isthmus block requires clear recognition of these disease processes. Understanding of the tympanic isthums as an anatomical entity is essential in the management of middle ear and attic disease.     

Use of reconstructed,non-orthogonal plane,high-resolution computed tomography of the temporal bone in the planning of temporal bone surgery

OBJECTIVES: To demonstrate the utility of high-resolution computed tomography (HRCT) reconstructed in non-orthogonal planes in the planning of temporal bone surgery. STUDY DESIGN: Qualitative and quantitative comparison of in vivo anatomic measurements between orthogonal and non-orthogonal plane reformatted HRCT of the temporal bone. METHODS: HRCT data of 10 normal temporal bones were reconstructed two-dimensionally in two non-orthogonal planes. Parallel to the plane defined by the superior semicircular canal (defined as transverse) as well as perpendicular to the plane defined by the superior semicircular canal (defined as longitudinal). This was done using commercially available software. Sixteen surgically important relationships between neural, vascular and/or bony structures were measured and analyzed. RESULTS: Quantitatively, wide variations were obtained in the measurements obtained from images of both non-orthogonal planar orientations. These variations were not age or sex dependent. Qualitatively, the images obtained highlight the anatomy of the temporal bone and skull base as it will be encountered during otologic surgery, since the surgical visual axis is along the long axis of the temporal bone. CONCLUSIONS: The reformatted images in non-orthogonal planes were superior to the axial and coronal series because they condensed critical relationships into a single perspective which promoted an intuitive understanding of the surgical approach. These reconstructed images show wide differences in quantitative measurements between surgically relevant landmarks. The protocol can be easily implemented in the clinical setting and is a potentially valuable educational tool. We recommend that non-orthogonal reconstructed images be routinely included with orthogonal temporal bone HRCT scans.     

Imaging of the parapharyngeal space

The parapharyngeal space (PPS) is a space in the suprahyoid neck that contains fat and is surrounded by several other spaces defined by the fascial layers of the neck. This article presents the spatial anatomy of the PPS and describes the displacement patterns of the PPS fat that are essential for accurate diagnosis and appropriate treatment of pathology arising in this region.     

大型、巨大型垂体腺瘤导致周围重要结构异常改变的观测

目的：探查大型、巨大型垂体腺瘤周围重要结构的变异情况。方法：在１９例垂体瘤病人进行显微手术切除术时，观察其变异情况。结果：１）视神经、视交叉全部被牵拉、受压、抬高，部分与肿瘤发生粘连。２）鞍膈全部向上隆起，在肿瘤上长出分叶的小肿瘤处鞍膈破溃。垂体柄被挤压在鞍膈的后下方。３）视交叉池不完整，在粘连及垂体柄进入鞍膈处，蛛网膜下腔已经消失；在肿瘤挤压（包括动脉）处，蛛网膜下腔仅为一潜在腔隙。４）凡被肿瘤挤压、包围、发生粘连的硬脑膜、神经及血管均有肿瘤新生血管形成。结论：大型、巨大型垂体腺瘤对周围重要结构产生挤压，发生粘连，部分蛛网膜下腔消失，并有肿瘤新生血管形成。以上异常与肿瘤大小及生长方向直接相关。了解上述规律，有利于提高手术疗效     

咽旁隙肿瘤的MRI诊断

目的 探讨咽旁隙肿瘤的ＭＲＩ表现特点及其临床诊断价值。方法 对２９例手术病理证实的咽旁隙肿瘤的ＭＲＩ征象进行分析，并以手术和病理结果相比较。结果 ＭＲＩ对咽旁隙肿瘤定位和定性准确；不同组织来源的肿瘤与周围组织的关系在ＭＲＩ特征上有不同；良性肿瘤界限清楚，信号分布均匀，Ｔ１ＷＩ主要表现为中等信号；恶性肿瘤信号分布不均匀，Ｔ１ＷＩ表现为低中信号。结论 本研究结果证实，ＭＲＩ在诊断咽旁隙肿瘤中有其自身的     

Navigated control: a new concept in computer assisted ENT-surgery

This work conceived and evaluates a mechatronical system for ORL-surgery by example of a Shaver for Functional Endoscopic Sinus Surgery controlled by navigation. The Shaver is automatically on/off-regulated depending on the current position in relation to the planned working space. This working space is defined on the basis of the individual CT data. Within this area the Shaver reacts to the signal of the surgeon (foot pedal). If the Shaver leaves the working space, an interruption of the drive regulation to the Shaver takes place. The evaluation of the planning software based on 32 patient CT-data sets. The registration accuracy in a anatomical model was examined on 451 measurements of endonasal attached titanium screws. The conversions of the working space were evaluated at 5 different technical models. The average time for segmenting the working space was found at 4.23 minutes per case. An average registration accuracy of the Shaver of 1.08 mm resulted. The pre-defined cavity was to be cleared away without restrictions. The preoperative determined work-space was converted by 3.1 mm over all levels. The study proves the feasibility of a mechatronical assistant system by the example of the navigate-controlled Shaver in paranasal sinus surgery. Contrary to conventional CAS solutions redundancy and cognitive discharge of the surgeon are considered in this conception. We see numerous applications according to the explained principle for power-control of instruments in ORL-surgery in the future such as drilling, high frequency surgery or laser.     

Untersuchungen über die Foetalentwicklung des Prussakschen Raumes

Summary The development of Prussak's space is studied in 90 fetal temporal bones between the 9th and 25th week.Bone, connective tissue, mucosa, and air spaces are examined. The findings are compared with older studies on smaller numbers of temporal bones.A monolayer epithelium is lining the spaces covering an initially undifferentiated connective tissue. The formation of the middle air space shows considerable individual variations.     

Klinische Anatomie des Os temporale

Detailed knowledge of the complicated anatomy and topography of the temporal bone is a crucial basis for successful ear surgery. In particular, the topographical relations to the essential neighbouring structures (e.g. intratemporal vessels and nerves, neighbouring spaces, especially the endocranium) are of vital importance. Furthermore, typical landmarks play an essential role in topographic orientation. However, this knowledge cannot be acquired from lectures or books, but can only be achieved by independently performing numerous dissections and drill exercises on the temporal bone, once a theoretical understanding of the various structures and regions has been gained on the basis of a clearly defined nomenclature. Furthermore, there are essential anatomical variations which may lead to complicated anatomical conditions. The surgeon must also be familiar with these peculiarities.     

Two-tone interactions in the cochlear microphonic

Two-tone interactions are explored for the cochlear microphonic (CM) in the guinea pig. Recordings are made from turns one and three using differential electrodes in the perilymphatic space or pipettes placed in scala media through a fenestra over the stria vascularis. We focus on magnitude changes associated with the introduction of appropriate interference tones and on various types of phase shift concomitant with these magnitude variations that have not received documentation in the literature. Based on extensive parametric data, it is suggested that some features of the gross interference phenomenon may be a consequence of the vectorial summation of outputs from contributing hair cell generators. These spatial effects appear to determine phase behavior and the influence of probe frequency on the frequency of maximal interference. In addition, the apparent interval between our defined best frequency (CF) and the frequency of maximal interference is most likely due to an underestimation of CF resulting from phase cancellation between CM-producing hair cell populations. However, after compensating for these spatial effects, several aspects of the CM interference phenomenon seem to be analogous to two-tone suppression in auditory nerve fibers. A direct one-to-one relationship is not implied since the latter reflect the outputs of inner hair cells while CM interference most likely reflects outer hair cell behavior. As a result, the association between suppression and interference must be sought in the process by which outer hair cells influence inner hair cell transduction.     

Sound-Localization Experiments with Barn Owls in Virtual Space: Influence of Interaural Time Difference on Head-Turning Behavior

Specific cues in a sound signal are naturally linked to certain parameters in acoustic space. In the barn owl, interaural time difference (ITD) varies mainly with azimuth, while interaural level difference (ILD) varies mainly with elevation. Previous data suggested that ITD is indeed the main cue for azimuthal sound localization in this species, while ILD is an important cue for elevational sound localization. The exact contributions of these parameters could be tested only indirectly because it was not possible to generate a stimulus that contained all relevant spatial information on the one hand, and allowed for a clean separation of these parameters on the other hand. Virtual auditory worlds offer this opportunity. Here we show that barn owls responded to azimuthal variations in virtual space in the same way as to variations in free-field stimuli. We interpret the increase of turning angle with sound-source azimuths (up to +/- 140 degrees) such that the owls did not experience front/back confusions with virtual stimuli. We then separated the influence of ITD from the influence of all other stimulus parameters by fixing the overall ITD in virtual stimuli to a constant value (+100 micros or +100 micros) while leaving all other sound characteristics unchanged. This manipulation influenced both azimuthal and elevational components of head arms. Since the owls' azimuthal head-turn amplitude always resembled the value signified by the ITD, these data demonstrated that azimuthal sound localization is influenced only by ITD both in the frontal hemisphere and in large parts of the rear hemisphere. ILDs did not have an influence on azimuthal components of head turns. While response latency to normal virtual stimuli was found to be largely independent of stimulus position, response delays of the head turns became longer if the ITD information pointed into a different hemisphere as the other cues of the sounds.     

Measurement of parapharyngeal space using CT images

Parapharyngeal space can be defined as a potential space surrounded by deglutitional and masticator muscles and their covering, superficial and middle layer of deep cervical fascia. It is easily recognized in images provided by modern scanning devices, such as CT and MRI. Parapharyngeal space has traditionally been divided by styloid process and fascia of tensor veli palatini muscle (nasopharyngeal level) or fascia of stylopharyngeus muscle (oropharyngeal level) into two compartments, prestyloid and postsyloid spaces. The latter is often called as carotid space. Prestyloid portion exclusively contains fat tissue, which yields hypoabsorption area in CT films and high density area in MRI. In most of papers in radiological journals, the term of parapharyngeal space is regarded as its prestyloid portion which is clearly identified. Axial CT images of 144 patients without any naso- or oropharyngeal lesions were analyzed. Two reference levels of nasopharynx were adopted for the study. The upper level passes through the plane of fossa of Rosenmuller, and the lower reference level transects soft palate. The following parameters of the space were measured; Length and width of the whole space, length and width of prestyloid fatty space, and furthermore, width of pre- and poststyloid space, that were divided by a imaginary line parallel to the axis of the whole space (the upper level); Length and width of the whole space, length of base and height of a triangle of the prestyloid part (the lower level). While parapharyngeal space was symmetrical in the upper level, the rate of asymmetry amounted to a fourth in the lower level.(ABSTRACT TRUNCATED AT 250 WORDS)     

Variations of the anatomical position of the internal carotid artery as an important differential diagnosis of parapharyngeal tumors

PATIENT: A case of a 78-year-old man with globus syndrome is reported who was referred to our department because of a tumor of the right parapharyngeal wall. Radiological and endoscopic examination revealed that the tumor was caused by an extracranial kinking of the right internal carotid artery. DISCUSSION: Variations of the anatomical position of the internal carotid artery in the parapharyngeal space are potentially at risk during routine ENT-procedures such as adenoidectomy and tonsillectomy or during endoscopic procedures with diagnostic biopsies. Data about the frequency of variations of the clinical course of the internal carotid artery dorsolateral of the lateral pharyngeal wall vary in literature from 4% to 66%. By cost-effective ultrasound and duplex-ultrasound, computed-tomography, magnetic resonance imaging with angiography or by conventional angiography a wide variety of different diagnostic imaging methods is available. While coiling of the internal carotid artery is ascribed to embryological malformation, elongation and kinking of the artery are due to atherosclerosis or fibromuscular dysplasia. These variations are often asymptomatic but they can also cause symptoms from globus syndrome to cerebrovascular insufficiency producing ischemic attacks or infarction. This case report emphasizes the clinical importance of variations of the clinical course of the internal carotid artery as a differential diagnosis of parapharyngeal tumors since iatrogenic injuries during routine pharyngeal surgery with disastrous outcome were frequently reported in literature. Unexperienced ENT-surgeons should be warned and experienced ENT-surgeons should be reminded of those dangerous variations.     

Aging and the peripheral vestibular system

Whereas much has been learned about age-related auditory changes in the inner ear, relatively little is known about the aging effects on the vestibular part of the inner ear-the peripheral vestibular system. Here we review relevant literature with regard to the prevalence of vestibular dysfunction, vestibular functional and structural changes in the elderly. The prevalence of vestibular dysfunction increases with age. Functionally, as age increases, VEMP amplitudes decrease, VEMP thresholds increase, VOR gain of HIT decreases. Due to the complexity of the vestibular system, variations in subject age and measurement techniques, findings in VEMP latency and caloric tests are conflicting. To address this, a direct measure of the peripheral vestibular system should be applied. Structurally, age-related loss in vestibular ganglion and otoconia have been noted; hair cell changes are not well defined; while subcellular changes remain to be explored. Defining how the onset of vestibular dysfunction correlates with structural degeneration will offer insights into the mechanisms underlying vestibular aging.     

Desarrollo de algoritmo clínico para el diagnóstico de tumores del espacio parafaríngeo. Revisión sistemática

IntroductionParapharyngeal space (PPS) is defined as a deep space, located around the upper pharynx, in the shape of an inverted pyramid. Primary tumours in this region are rare, accounting for 0.5% of head and neck neoplasms, and most are benign. The objective of this study is to propose a new study algorithm based on a systematic review and our experience.Materials and methodsA cross-sectional and analytical study was carried out through review of the clinical records of our hospital. Patients with tumours of the parapharyngeal space operated from January 2010 to December 2019 and a systematic review of Pubmed studies from the last 5 years were included. We considered clinical signs, diagnostic methods, presumptive diagnosis and histopathological findings. Statistical analysis was performed with STATA v.14 software.Results53 of our cases and 1392 from the review were included. The clinical algorithm showed a sensitivity of 76.4% and a specificity of 96.3%, with an AUC of 0.57 for diagnosis.DiscussionComplementary radiological examinations are essential in the topographic diagnosis of the tumour. Angio-MRI links the tissue of origin of the tumours and provides the highest diagnostic certainty. FNA has some disadvantages in PPS, but it is useful in some patients.ConclusionThe proposed algorithm contributes to obtaining excellent results in the management of these tumours because it turned out to be effective in diagnosis, and this enables improved surgical planning.     

Assessment of Cottle's areas through the application of a mathematical model deriving from acoustic rhinometry and rhinomanometric data

Objectives: Each nasal area, as defined by Cottle, has a different influence on the nasal airflow. The longitudinal distribution of resistances in nasal cavities was calculated by the anterior rhinomanometry and acoustic rhinometry data. Design: Dynamic study of Cottle's areas in normal subjects was carried out by rhinomanometry and acoustic rhinometry. Setting: Study by the Department of Otolaryngology of the University of Rome‐La Sapienza. Participants: Twenty‐seven Caucasian adults in local and general healthy conditions took part and completed this study, with a total of 54 nasal cavities included because of negativity at ENT‐examination and clinical history, with normal respiratory parameters at the rhinomanometry and acoustic rhinometry. Main outcome measures: We determined nasal and acoustic resistances, nasal volumes and cross‐sectional surface areas, as defined by Cottle, using nasal endoscopy. The longitudinal distribution of nasal resistances was obtained by integrating experimental surface areas using a novel mathematical model. The estimation of the longitudinal nasal resistance variations as a result of a theoretical reduction of the surface areas. Results: The reduction of the 2–3–1 areas (in this order of importance) showed the greatest influence on the nasal resistances with coefficients of determinations greater than 0.98, this being quite different from that of the areas 4 and 5 for quite smaller area reduction percentages. Conclusions: The areas 2–3–1 control the overall nasal resistance so the surgical procedures on these areas greatly influence the dynamics of nasal airflow. The mathematical model developed here gives useful information to nasal functional surgery and may be applied to other schemes of nasal cavity.     

Anatomical markers of Reinke's space and the etiopathogenesis of Reinke edema

On the basis of histological examination of normal human larynges, the authors have defined the anatomical and histological features of Reinke's space. It is sharply demarcated by dense fibrous tissue in the anterior commissure, along the vocal process of the arytenoid and beneath the free margin of the vocal cord. The upper limit is not always sharply demarcated, and on the upper surface Reinke's space varies considerably in size. It may include a half of the upper surface of the vocal cord, reaching usually to the bottom of the laryngeal ventricle and occasionally extending to include also the inferior surface of the ventricular fold. The authors suggest that the upper boundary of Reinke's space is functional. On the basis of the morphologic structure of Reinke's space a hypothesis of aetiopathogenesis of Reinke's oedema was set up. The patient's attempt to compensate the hoarseness by the use of the false vocal cords forces the fluid within Reinke's space towards the free edge of the vocal cord.     

Ultrastructural analysis of 20 intraosseous endolymphatic sacs from patients with cerebello-pontine angle tumours. A surgically obtained control material for histopathological studies

Objective: The purpose of this work was to collect a surgically obtained, freshly fixed material of the human intraosseous endolymphatic sac. This biopsy material was used to describe the normal ultrastructure as well as to serve as a control material for histopathological studies on Ménière’s disease in particular. Method: The specimens, obtained during surgery for cerebello-pontine angle tumours, were fixed by immersion and then prepared by routine methods for transmission electron microscopy. The ultrastructural analysis was focused on intraluminal content, epithelial cell layer, subepithelial space, and morphological signs of immunological activity. The ultrastructure was analysed in relation to inner ear sensory function, tumour diagnosis, and patient’s age and sex. Results: As it was possible to obtain numerous specimens with an intact bony shell, the intraluminal substance could be analysed. Two separate epithelial cell types are described: one less abundant, often lighter and mitochondria-rich cell type; the other, often darker, epithelial cell with fever mitochondrias. Some of the latter cell types showed signs of active secretion. The subepithelial space was characterized by loose connective tissue adjacent to the epithelial lining, being more dense toward the bone. Elastic fibres were seen surrounding the entire endolymphatic sac. Macrophages in the intraluminal space and lymphocytes in the epithelial and subepithelial layers are described. No distinct morphology correlating to inner ear sensory function, tumour diagnosis, or patient’s age and sex was revealed. Conclusions: This study confirms previously described, extensive variations in form and structure of the human endolymphatic sac. Various factors, such as surgical trauma, previous treatment, and processing method, can affect the ultrastructure and must be taken into consideration. The specimens described in this work appear to constitute a good control material for histopathological study of the human endolymphatic sac. It is still necessary to obtain large control materials such as this, as surgical specimens from patients with Ménière’s disease are uncommon.     

Estimation of perilymph concentration of agents applied to the round window membrane by microdialysis

OBJECTIVE: The round window membrane (RWM) is known to be permeable to various biological substances. Application of biological substances to the RWM has been shown to affect inner ear fluid composition and damage hair cells, resulting in functional changes RWM instillation of gentamicin, a preferentially vestibulotoxic aminoglycoside, is used as a therapeutic treatment for patients with intractable vertigo and is gaining acceptance as a chemical vestibular ablation agent, despite considerable variations in the incidence and severity of hearing loss associated with gentamicin. Clearly, the susceptibility of vestibular and auditory hair cells to the ototoxic effects of gentamicin is not well understood. The aim of this study was to understand the kinetics of urea and methylene blue instilled into the inner ear space through the RWM and to establish a method for determining the optimal dosage for the treatment of inner ear disorders. MATERIAL AND METHODS: We used inner ear microdialysis to quantify changes in perilymph concentration of low molecular weight agents applied to the RWM in a chinchilla model. RESULTS: Preliminary results after placement of a microdialysis probe and application of a low molecular weight marker (urea) to the RWM were extrapolated from a time versus concentration plot from dialysates sampled over a 3-min interval using modifications of standard microdialysis equations for estimation of in vivo recovery. Our data suggest that inner ear microdialysis can be used to measure the pharmacokinetics of a low molecular weight agent within the perilymphatic space without the need for repeated direct sampling. CONCLUSION: Inner ear microdialysis may be a useful method for establishing a therapeutic dosage for ototoxic agents used in the treatment of inner ear disorders.