Die Bedeutung der Anamnese für die Frühdiagnose der Kleinhirnbrückenwinkeltumoren

Ohne Zusammenfassung     

Früher Gaumenspaltverschluss und Tübinger Atmungsgaumenplatte

CURRENT KNOWLEDGE: Children with Pierre Robin sequence (PRS) typically have difficulty with bolus transport and swallowing. Due to velopharyngeal insufficiency caused by the cleft palate, a high percentage of the children affected also have impaired Eustachian tube function. AIMS OF THE STUDY: In the literature, substantial information may be obtained on conductive hearing loss in PRS patients; however, no study has yet been performed to investigate whether wearing a soft palate plate and relatively early surgical cleft palate closure positively influence Eustachian tube function. In the present study this question was investigated. METHODS AND RESULTS: A total of 41 PRS children, 27 girls and 14 boys, were included in the study and were examined for hearing ability prior to and after surgical cleft palate closure. All of the children had been wearing a Tübingen soft palate plate until surgical cleft palate closure, which occurred at an age of 3-13 months (mean age 7.3 months). Based on data obtained prior to surgery by BERA, otoacoustic emissions and tympanometry, a hearing loss of more than 30 dB was diagnosed in 68.4% of the children. After 3-6 months, normal hearing ability was found in 70%. CONCLUSIONS: Wearing the Tübingen soft palate plate, and the improved swallowing function resulting from this, as well as early surgical cleft palate closure had a very positive impact on the hearing ability of the children included in the study.     

Navigationsunterstützte Weichteilsonographie für den Kopf-Hals-Bereich

Background

In soft tissue surgery of the head and neck region tissue shifts limit the usefulness of conventional CT/MRI-based navigation procedures. Furthermore, changes caused by invasive measures cannot be visualized.

Methods

A novel navigation device for sonography of soft tissues was developed. Thisconsists of a navigated ultrasound scanner, a navigated surgical instrument, and a personal computer with custom-made software. Its use makes an additional visualization by means of CT or MRI dispensable.

Results

The system deviation (three-dimensional error) of this newly developed prototype was less than 1 mm. The practical application in a model setup showed good handling properties of the system. Orientation and approach of the surgical instrument to the sonographically visualized target structure were rapid and accurate.

Conclusion

This new navigation system does not require additional CT or MRI images. The navigated ultrasound probe shows tissue changes in real time. This navigation system is especially suitable for invasive procedures in soft tissues     

Schilddrüsenmedizin für HNO‑Ärzte

Diseases of the thyroid gland are frequent incidental findings during ultrasound examination of the neck. They affect nearly one third of the normal population. Treatment is not always indicated; however, laboratory diagnostic measures must be initiated to specify the disease. The primary indications for consulting a thyroid specialist are thyroid nodules, goiters, autonomy of the thyroid gland, autoimmune diseases, Graves’ disease, and Hashimoto thyroiditis. The aim of this review is to provide an overview of the most important thyroid diseases and their treatment options.     

Steigbügelchirurgie

Background

The first hearing results with a new stapes prosthesis with clip function (Soft-CliP® piston) are presented.

Patients and Methods

This new prosthesis was used in 15 patients (mean age 45.2 years; range 21-63 years) undergoing routine stapes surgery. Soft-CliP® piston prostheses with a shaft diameter of 0.4 mm and a length ranging from 4.25 mm to 5.5 mm were used. Postoperative audiological testing and measurement of the air-bone gap were performed after an average of 47.3 days and compared with the preoperative values.

Results

The median observed postoperative air-bone gap (ABG) was 8.33 dB ±4.16 dB. All patients had less than 20 dB ABG and in 53.3% of cases was less than 10 dB. The operating time showed a clear difference between the left (66.5 min ±37.79 min) and right ears (47.2 min ±11.08 min).

Discussion

This new prosthesis design greatly facilitates a very difficult step in stapes surgery, the prosthesis fixation to the incus. The first postoperative hearing results are very promising but long-term results in a larger group of patients are still pending.     

Ein Konzept für eine automatisierte Endoskopführung für die Nasennebenhöhlenchirurgie

Background

Functional endoscopic sinus surgery (FESS) is characterized by single-handed preparation and guidance of the endoscope by the nondominant hand. This results in an additional extension of operation time by up to 15% and ergonomic deficits. The aim of this study is the conception of an automated assistance system for FESS in view of the following questions: (1) Which degree of surgical automation is suitable for FESS? (2) Which design is suitable? (3) What are the properties of the technical system (planning, time, accuracy, precision) of the selected system? (4) Does the system offer potential for a clinical application?

Methods

In all 49 FESS were analyzed for surgical workflows. Measurement of the maximum forces within FESS was performed with 40 trials on an anatomical model. Three different mechanical systems were used in ten FESS and evaluated using the ICCAS Human-Machine Evaluation Scale. For realization of automated endoscope guidance an engine-driven and -braked manipulator (PA10–6c, Mitsubishi, Japan) was used. The technical parameters determined were expenditure of time for the preoperative planning of workspace, surgical accuracy and precision of the intraoperative endoscope positioning, maximal forces, and time.

Results

Concept-conditioned instrument changes amount to an average of 41.1 and 18.9% (5.21 min) time requirement for each FESS side. Maximum forces on the mucous membrane during a conventional FESS were measured at 9.8 N (5.9–9.8). Usability of the mechanical endoscope holder was estimated in 18 of 20 cases to be inferior to the standard procedure. The time needed for segmenting the intranasal workspace was 15.2 min (10.0–23.0). The maximum deviation of the automatically driven endoscope from a planned position amounted to 0.85 mm (manually 4.64 mm). The maximum force was measured with 1.1 N in the z direction (manually 9.8 N). Automated guidance of the endoscope to an intranasal position needed 7.25 s (6.4?7.9); manually 12.64 s (5.9?43.0).

Conclusion

Guidance of the endoscope for FESS by an automated motor-driven system is possible. The conception which is based on workflow analysis favors a system with automatic definition of the workspace and a manual movement of the endoscope. The examined system offers a potential for clinical application. Definition of the automation level and development of a man-machine interface is more important than selection or reconstruction of a special manipulator for endoscope guidance in FESS from a surgical point of view.     

Das Schilddrüsenmalignom

Background

Thyroid carcinoma is frequently diagnosed incidentally during routine ENT examinations.

Methods

Symptoms and clinical findings of 40 patients with thyroid malignancies presenting in our department were analysed retrospectively. The aim was to define characteristics indicative for the final diagnosis of thyroid malignancy.

Results

In 48% the initial presentation was not because of thyroid-specific complaints, however during the course of the general ENT examination, unspecific thyroid pathology was detected and further evaluated using sonography, scintigraphy and fine needle biopsy (FNB). The results of scintigraphy were suspicious in 67% and FNB was positive in 30%, inconclusive in 30% and false negative in 40%. For suspected malignancies a rapid frozen section examination was carried out which was positive only in 60% and false negative or inconclusive in 20% each.

Conclusion

Thyroid lesions incidentally found during ENT examination should undergo ultrasound examination, FNB and scintigraphy with the clear understanding that there is no single diagnostic feature leading to the correct diagnosis and that only the synopsis of various findings and sometimes only final histology leads to the correct diagnosis.     

Entzündungsübertragung zwischen Kieferhöhle und Endokranium

BACKGROUND: Rhinogenous brain abscesses usually originate from a frontal sinusitis, rarely from the ethmoidal system or the maxillary sinus. However, there are different pathways that can lead to the transfer of a maxillary infection to the endocranial compartment. PATIENT: A patient with frontal brain abscesses originating from a maxillary sinus infection is presented and diagnostic steps, therapy as well as pathophysiology are discussed. PATHOPHYSIOLOGY: The venous plexus of the maxillary sinus drains through the posterior wall of the antrum of Highmore into the deep facial vein that leads into the pterygoid plexus and then through the rete foraminis ovalis into the cavernous sinus. In addition, numerous small veins perforate the osseous roof of the maxillary sinus and enter the orbit joining the superior or inferior ophthalmic vein. They are also connected to the cavernous sinus or the pterygoid plexus. A number of veins perforate the anterior wall of the maxillary sinus communicating with the angular vein that drains into the superior ophthalmic vein and into the cavernous sinus. From the cavernous sinus, the blood arrives at the deep middle cerebral vein that usually communicates through the white substance towards the brain's superficial venous system. CONCLUSION: The presence of these maxillo-cerebral venous anastomoses explains the spread of infection from the maxillary sinus to the white substance of the brain without any direct association with the base of the skull.     

Gezüchtete Knorpeltransplantate

Background

The main technique used in tissue engineering for the generation of autologous cartilage grafts is the production of autologous transplant material from living cells or tissues and/or cell matrices. Incompletely absorbed residual fibrous matter, unforeseeable interactions between cells and biological materials and uneven cell distribution of cells in the cell carriers still present unsolved problems.

Methods

For these reasons a three-dimensional aggregate culture system was developed in which cells can generate cartilaginous tissue without the use of biomaterials. Chondrocytes and adult mesenchymal stem cells were used for this purpose and generate cartilaginous tissue with various phenotypes both in the aggregate culture system and in the athymic nude mouse model. The newly generated cartilage was subjected to histomorphological, immunochemical and biochemical investigation.

Results

After 3 weeks of in vitro aggregate culture the chondrocytes of all subclasses formed cartilaginous tissue. After 6 weeks’ in vivo maturation in the athymic nude mouse model the new cartilage was found to differ in typical phenotype depending on the native cartilage used.

Conclusions

Cartilage cells of various subclasses and adult menchymal stem cells generate cartilaginous tissue corresponding to their own phenotypes in a 3D aggregate culture system. This culture system is a promising method of producing cartilage grafts for use in reconstructive head and neck surgery.     

Hörgeräteüberprüfung in der Praxis

A qualified hearing aid fitting is only possible if the ENT doctor not only prescribes the device, but also conscientiously checks the comparative adjustments made by the hearing aid acoustician. In deciding, which of the tested hearing aids achieves the best and most appropriate improvement of hearing, the physician should first thoroughly study the acoustician's fitting protocol, which contains comparative results of all devices tested. The subjective satisfaction of the patient with his hearing aid can be determined in a detailed conversation or with a special questionnaire. The examination of the otoplastic is as necessary as the improvement of speech discrimination under free field conditions, especially with additional noise. With in situ measurement, the individual transmission characteristics of the hearing aid and the otoplastic are tested in a few minutes. Conscientious control of the fitted hearing aid is only possible with loudness scaling. The scaling function shows clearly whether the fitted aid has adequate amplification, is not too loudly adjusted, and whether the field of pleasant hearing has been considered.     

Gebührenordnung für Ärzte – Abrechnung nach Standardtarif

Seit dem 01. Januar 2000 gilt in der Amtlichen Gebührenordnung für ?rzte (GO?) der durch das Gesundheitsreformgesetz 2000 neu eingeführte § 5b. Danach sind die ?rzte gesetzlich verpflichtet, Leistungen bei Standardtarifversicherten zu reduzierten Gebührens?tzen zu berechnen. Mit der Verankerung eines gesetzlich vorgeschriebenen Tarifs des Versicherungsgewerbes in einer Amtlichen Gebührenordnung ist erstmalig ein Systembruch erfolgt.     

Fazialisrehabilitation nach Kleinhirnbrückenwinkelchirurgie

Ohne Zusammenfassung     

Computerunterstützte 3D-Navigationssysteme

3D-navigation systems have only recently been introduced into the surgical field. Since then they have gained increasing importance not only in ENT surgery but also in neurosurgery, orthopedic surgery, maxillo-facial surgery, radiology and radiotherapy. Following a brief historical introduction this article reviews existing navigation technologies, in terms of indication, practicability, accuracy, forensic and financial aspects. The selection of the navigation system is strongly influenced by the planned procedure (endoscopic, microscopic, open approach). According to our experience most of these systems provide useful support intraoperatively. The clinical application accuracy regularly lies in the range of 1-2 mm.     

Visceralbogenmißbildungen unter Berücksichtigung von Entwicklungsgeschichte und Conterganeinflüssen

Zusammenfassung Die verschiedenen isolierten und die kombinierten Fehlbildungen des Visceralbogenbereiches werden einer entwicklungsphysiologischen Einheitsbetrachtung unterzogen. Die Berechtigung dazu wird auch durch 25 eigene, einschlägige, tabellarisch zusammengestellte Beobachtungen unterstrichen. Die engeren Zusammenhänge der im einzelnen sehr verschieden erscheinenden Bilder finden ihre Erklärung im besprochenen Determinationsgeschehen, auf das verschiedenste Einflüsse, auch medikamentöse, wirken. Genauere Aufschlüsse sind von der Auswertung der Thalidomidschäden zu erwarten, da sie zu Phänokopien schon bekannter Ohrmißbildungen führen konnten.Mehrere Fälle unserer Zusammenstellung weisen die charakteristische Symptomenkonstellation der Dysostosis mandibulo-facialis auf. Bei einem Vater war sie einmal nur halbseitig, bei seiner Tochter hingegen beidseitig ausgeprägt. Unter der hier vorgenommenen Betrachtungsweise erscheint es kaum als Besonderheit, daß immer wieder auch Zufallskombinationen beobachtet werden. Ein hier erstmals beschriebener Mißbildungskomplex des Visceralbogenbereiches weist überdies Generalisierungstendenz auf. Bemerkenswert ist der hohe Prozentsatz von Facialisfehlbildungen, ohne daß zum gegebenen Zeitpunkt eine Abhängigkeit von Thalidomideinnahme als erwiesen gelten könnte. Das Wissen um teratogene medikamentöse Schädigungen erfordert aber auf jeden Fall die äußerste Beschränkung nicht nur radiologischer, sondern auch chemischer Therapie in den sensiblen Schwangerschaftsphasen.Mit 6 Textabbildungen     

Automatische Registration des Patienten mit A-Mode-Ultraschall für computerunterstützte Chirurgie

Background

The main source of error in 3D navigation is the patient-to-image registration process. Anatomical landmarks or adhesive markers perform sub-optimally. Bone-anchored invasive markers significantly change the clinical workflow of navigated ENT surgery, are invasive and cause patient discomfort. In order to minimize registration errors and to further streamline the clinical use of intraoperative 3D navigation we demonstrate that A-mode ultrasound allows an accurate 3D surface profile of the os occipitale to be created which can be reliably registered on preoperative patient CT data.

Methods

The transducer is mechanically positioned with sub-millimeter accuracy on the patient’s occiput. From the sound echos a 3D surface is generated and registered to the preoperative CT images with the iterative closest point (ICP) algorithm. The evaluation of our setup was performed on three anatomic specimens and one bony skull.

Results

The ultrasound echoes from the occiput allowed the creation of an adequate 3D surface which could be registered to a segmentation of the CT image with an accuracy greater than 1.5 mm. The experiments were evaluated by an intuitive representation of the spatial deviation between CT and ultrasound data as a color-coded map.

Conclusion

The approach to scan the posterior skull with A-mode ultrasound enables automatic intraoperative registration and can be integrated into the intraoperative setup.     

Grundlagenuntersuchungen für Stimmlippendynamik

Background

The understanding of normal and pathological vocal fold dynamics is the basis for a pathophysiological motivated voice therapy. Crucial vocal fold dynamics concerning voice production occur at the medial part of the vocal fold which is seen as the most critical region of mucosal wave propagation. Due to the limited size of the larynx the possibilities of laryngeal imaging by endoscopic techniques are limited.

Material and methods

This work describes an experimental set-up that enables quantification of the entire medial and superior vocal fold surface using excised human and in vivo canine larynges.

Results

The data obtained enable analysis of vocal fold deflections, velocities, and mucosal wave propagation. The reciprocal dependencies can be examined and different areas of vocal fold dynamics located. The vertical components obscured in clinical endoscopy can be visualized. This is not negligible.

Conclusions

In particular it is shown that the vertical deflection, which cannot be observed by clinical examination, plays an important part in the dynamics and therefore cannot be omitted for therapeutic procedures. The theoretically assumed entrainment and influence of the two main vibration modes enabling normal phonation is confirmed.