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.     

In-vitro-Bestimmung zytotoxischer Aktivität in Speichelproben von Rauchern

Background. The question arised whether saliva can be included in populations monitoring of high risk groups for the development of head and neck squamous cell carcinomas. Cytotoxic mechanisms strongly influence the carcinogenesis of squamous cell carcinomas. Patients and methods. Saliva specimen of 131 abusing and non-abusing probands were tested on their biological (cytotoxic) effects to draw conclusions on the individual cancer risk. To determine the cytotoxic activity of saliva, we used the “plating efficiency index” of lungfibroblasts of the chinese hamster. Results. We found significantly increased cytotoxic effects in the saliva of smoking probands (p<0.002). Regularly combined smoking and drinking of alcohol led to a highly significant increased risk of cytotoxic saliva in the tested persons (odds ratio: 17.4; p<0.005). Conclusions. Including patients with head and neck squamous cell carcinomas, ongoing studies must prove the practical relevance of this biomarker for estimating the relative cancer risk in the upper aerodigestive tract.     

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.     

Untersuchungen zum Einfluss von Biokeramiken auf biologische Leistungen von Mikroorganismen

Background and objective. Biomaterials that come into contact with microorganisms in the middle ear or paranasal sinuses should be tested before clinical application. Thus, it is necessary to test the influence exerted on bacterial growth by biomaterials used as bone substitutes in head and neck surgery before implantation. Patients and methods. In this study, Bioverit, Al₂O₃ ceramic, and glass carbon were subjected to contamination with typical microorganisms in the middle ear and paranasal sinuses such as Staphylococcus aureus, Streptococcus pneumoniae and salivarius, Escherichia coli, Pseudomonas aeruginosa, Proteus mirabilis and Candida albicans. Results. In the suspension test, all gram-negative species were inhibited, but gram-positive microorganisms and Candida albicans were not affected. The Al₂O₃ ceramic showed the largest inhibition effect while growth inhibition of glass carbon was low. Streptococcus pneumoniae and salivarius can use glass carbon as a nutrient. In contrast, Bioverit and Al₂O₃ ceramic could not improve the growth of all tested microorganisms. Conclusions. In conclusion, we think that Bioverit is suitable for implantation in bacterially contaminated regions of the head and neck, whereas glass carbon is unsuitable for this application in reconstructive surgery.     

Tumoroxygenierung unter kombinierter Ganzkörperhyperthermie und Polychemotherapie Untersuchungen am Beispiel eines Rezidivkarzinoms der Mundhöhle

Background and objective. Previous studies have reported synergistic effects of combined hyperthermia and chemotherapy and/or irradiation. The response to irradiation and chemotherapy of well-oxygenated and vascularized tumors generally is better than that of hypoxic tumors. Therefore, tumor oxygenation is recognized as an important predictive factor in the therapy of malignant tumors. In practice, the head and neck area remains outside of the hyperthermia chamber during whole-body hyperthermia. It was the aim of this study to evaluate if the head and neck region receives sufficient warmth and, if so, if tumor oxygenation increases accordingly. Patients/methods. Whole-body hyperthermia, as heat radiation (Enthermics Medical Systems RHS-7500), was applied to the narcotised 60-year-old male patient with a local recurrence tumor pT₃ pN_2b M₀ squamous cell carcinoma of the oral cavity. Tumor oxygenation and temperature were measured by LICOX catheters via one-point measurement during the entire hyperthermia treatment (3.5 h). Parallelly, chemotherapy (ifosfamide/Carboplatin) was given in four cycles (one cycle/month). Results. With a latency of 10 min the increase of intratumoral temperature was comparable to temperatures achieved in the esophagus. The maximum intratumoral temperature was 41.8°C. The average increase in tumor oxygenation was more than 100%. The clinical outcome in the case presented was a partial tumor remission (PR). Conclusions. During combined whole-body hyperthermia and polychemotherapy, tumor oxygenation is also significantly improved in the head and neck area, despite the fact that the head and neck area remained outside the hyperthermia chamber. The intratumoral temperature was comparable to esophageal and rectal temperatures.     

Sekretionshemmung exokriner Drüsen des Kopf-Hals-Bereiches durch Applikation von Botulinum Toxin A Therapie seltener Krankheitsbilder

Background. Hypersecretion disorders of the exocrine glands of the head and neck area are a therapeutic problem in the field of otorhinolaryngology. In the present study, we demonstrate the effectiveness of local injections of botulinum toxin A to block secretions of exocrine glands of the head and neck area. Patients and methods. Four patients suffering from hypersecretion disorders received local injections of botulinum toxin A. Two patients suffered from disorders of the salivary glands: one presented an idiopathic hypersialorrhea and another a salivary fistula after parotidectomy. A third patient suffered from epiphora and a further patient presented severe hyperhidrosis on the pilose head region. In a retrospective clinical study, the outcome of therapy was evaluated by clinical examination and chemical parameters. Results. Clear blocking of secretion in the treated glands could be demonstrated in all four cases. Possible side effects of the treatment could not be observed. Conclusions. The present study was able to demonstrate a clear blocking of secretion of the exocrine glands of the head and neck region through botulinum toxin A, offering an improvement in therapy especially for the innovative indication of blocking the salivary glands of the head.     

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.     

Sentinel-Lymphknotenexstirpation Behandlungsmethode des N0-Halses bei Patienten mit oralen und oropharyngealen Karzinomen

Background. The clinically non-metastatic neck is an unsolved problem in the treatment of oral and oropharyngeal squamous cell carcinomas. A rational procedure is looked for which is neither exaggerated nor neglects the needed safety. Patients and methods. 15 patients with primary squamous cell carcinomas of the oral cavity and the oropharynx, staging T1–4N0M0 were examined. After peritumoral intramucodermal injection of tc⁹⁹m-la-beled colloidal albumin the lymphoscintigraphy using γ-camera imaging prior and hand-held γ-probe during operation were used for identification of the nodes. Selective sentinel lymph node exstirpation was followed by radical tumor resection. Results. In all cases (n=41) lymph nodes could be detected, 40 of them were sentinel lymph nodes, distributed to all neck levels, in 5 cases bilateral drainage. 92.5% of sentinel lymph nodes could be actually removed. All but 1 (97.5%) were true-negative. In the positive case modified radical neck dissection harvested another affected node. Conclusions. Methodically seen, the sentinel procedure works well and might lead to reduced post-surgical morbidity in about 50% of patients with oral cancer. To date, the procedure should be confined to studies with special requirements to diagnostics and subsequent treatment.     

Combined radiochemotherapy in locally advanced nasopharyngeal carcinoma

Background. Nasopharyngeal cancer (NPC) is a tumor of epidermoid origin with an entirely different biological behavior than other carcinoma of the head and neck region. Patients/methods. A retrospective analysis was performed in 93 cases with locally advanced NPC treated with induction chemotherapy followed by radiation therapy (RT; 79 patients) or concomitant RT and chemotherapy. Results. Totally 66 patients (71%) achieved a complete response (CR), 68% of the patients treated with induction chemotherapy followed by RT, 86% with concomitant chemoradiotherapy. After a median follow-up of 5.5 years 28 out of these 66 relapsed, 25 of them locoregionally. Median time to progression was 22.5 months, median overall survival (OS) 45 months, 5-year actuarial survival was 41.5%. Age, T and N classification, histological type and type of chemotherapy were independent significant factors for OS. Conclusions. Combined chemotherapy and RT in patients with locally advanced NPC result in a high CR rate. The main problem remains the locoregional control. Randomized studies are needed in order to define the optimal use of chemotherapy in combination with RT.     

Psychische Belastung, Informiertheit und Behandlungserwartung von Eltern mit einem Cochlear Implant versorgten Kind

Established knowledge. It is known that parents of hard-of-hearing children suffer from an increase in psychosocial stress. Scientific question. How does the psychosocial situation of parents with children who have cochlear implants change during rehabilitation? Aim of study. It was the aim of this study to demonstrate how parents evaluate retrospectively their own psychological well-being during the process of rehabilitation. Methods and results. We interviewed 87 parents by questionnaire which were mailed to them. Fifty-seven mothers and 46 fathers responded (59% return rate). Parents reported a significant increase in stress, as perceived by themselves, after the time of diagnosis. Of the parents, 25% continued to suffer from psychic stress during rehabilitation as could be demonstrated by the SCL-90-R questionnaire criteria. The expectations by parents were realistic prior to implantation but thereafter increased significantly with time. Conclusions. The psychological state of parents during the critical phase, after a diagnosis of deafness has been made for their child, has to be considered. Even after an initial phase of shock, parents seemed to be stressed to an extent that required therapeutic intervention.     

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.     

Organ preservation in advanced laryngeal and hypopharyngeal carcinoma by primary radiochemotherapy. Results of a multicenter phase II study

Introduction. Regarding the promising results of international trials we conducted the first German prospective multicentre phase II trial for organ preservation with primary simultaneous chemoradiation in advanced laryngeal and hypopharyngeal cancer. Patients and methods. 28 of 30 recruited patients suffering from stage II and III (UICC) laryngeal and hypopharyngeal cancer were treated with primary simultaneous chemoradiation within an organ preservation program and monitored in follow-up of one year. Exclusion criteria included tumor infiltration of the laryngeal cartilage, bilateral neck nodes (N2c) and need for flap reconstruction in case of laryngectomy. The protocol included an accelerated concomitant boost chemoradiation (66 Gy) with Carboplatinum (70 mg/m² 1st and 5th week) and a restaging procedure one month after therapy. In case of residual disease, salvage laryngectomy and/or neck dissection were performed. Results. After follow-up of one year 20 of 28 patients (71%) were presented with stable complete remission and functionally preserved larynx. Of these 20 patients 3 developed pulmonary metastases, 1 secondary primary carcinoma of the lung and 3 neck metastases which needed neck dissections. The other patients showed in 4 cases relapsing tumor which was indicated for laryngectomy. One patient needed tracheotomy because of persisting edema and 2 patients died due to tumor progress. One patient died after complications due to salvage surgery. Conclusion. The organ preservation protocol was feasible with well tolerated early toxicity. Problems of screening for recurrent disease, salvage surgery and late toxicity should be noted and pronounced in patient information. Further studies should focus on the improvement of patient selection which could be realized by induction Chemotherapy (using new components like taxan) and/or use of prediction factors such as tumor volume and hemoglobin levels.     

Effect of information about hearing damage caused by loud music. For adolescents the music in discoteques is too loud despite loudness limits

Background. Information campaigns are regarded useful to prevent adolescents from hearing-damage due to loud music. This study examined whether adolescents who are informed on the risk of a hearing-damage, exhibit preventive behavior when attending discotheques. Method. 253 pupils (age 14 to 19 years) were interviewed about their disco attending habits and about their information on the risk associated with listening to loud music. Results. About 85% of the sample were informed about the risk. Informed and uninformed pupils did not significantly differ in the frequency of disco attendance nor in the frequency of using ear-plugs. However, significantly more informed pupils experienced disco music as too loud (p<0.05). Conclusions. Information influences the subjective appraisal of loudness perception, but has little effect on preventive behavior. Instead, experimental forms of educational campaigns may be more effective. Additional provisions (lowering sound levels in discotheques) are necessary.     

Die stationäre Intensivtherapie bei auditiven Verarbeitungs- und Wahrnehmungsstörungen im Kindesalter

Preliminary remarks. The prevalence of central auditory processing disorders (CAPD) is supposed to be 2–3% of all children. Given the number of affected children and restricted resources in the public health there is a need for an effective and evaluated therapeutic approaches. On the other hand the number of outcome studies is remarkably small. Patients and methods. The presented study reports strategies and pitfalls in outcome measurements of 34 children with CAPD, based upon a 3-weeks indoor therapeutic intervention. Diagnostic criteria of auditory processing and perception were recorded before and after therapy. Results. The data shows a highly significant improvement of certain perceptive abilities, including audiological parameters (dichotic testing, discrimination, loudness scaling) and awareness, psycholinguistic development and orthographic tests. Conclusion. The study demonstrates that an effective therapy of CAPD in children is possible and scientifically proven. Long term surveillance however seems to be necessary. It also has to be studied whether intensive indoor treatment is superior or equal to out clinic therapy.     

Serumkonzentrationen der löslichen Adhäsionsmoleküle sICAM-1 und sVCAM-1 bei Patienten mit malignen HNO-Tumoren

Background. Adhesion molecules are implicated in various stages of tumor progression and metastasis. Soluble forms of intercellular adhesion molecule-1 (sICAM-1) and vascular cell adhesion molecule-1 (sVCAM-1) were recently described. The aim of this study was to determine a differences in concentration of these molecules in patients with head and neck squamous cell carcinoma (HNSCC) compared to healthy controls. Patients and methods. We investigated the circulating levels of sICAM-1 and sVCAM-1 in sera from patients with various head and neck squamous cell carcinomas (n=52) as well as from normal, healthy controls (n=35). Serum concentrations were determined as serum immunoreactivity by using a quantitative sandwich enzyme immunoassay technique. For statistical analysis, the Student's t-test was performed. Results. The majority of the patients with HNSCC were found to have high concentrations of sICAM-1 and sVCAM-1. The mean level of sICAM-1 in patients was 313 ng/ml and in the control group 237 ng/ml (p=0.0005). The mean level of sVCAM-1 in patients was 624 ng/ml and in the control group 435 ng/ml (p=0.009). The concentrations of sICAM-1 and sVCAM-1 were significantly higher in HNSCC patients. Conclusions. These results show the difference in expression of these adhesion molecules in patients with HNSCC compared to healthy controls. Endothelial adhesion molecule determination may find clinical applications in the follow-up of cancer therapy. For this reason, studies incorporating the longitudinal follow-up of patients are required.     

Die Bedeutung des SISI-Tests im Rahmen der Begutachtung von Lärmschwerhörigkeiten

Background and objective. Proof of cochlear hearing loss is an essential prerequisite for the diagnosis of noise deafness. For this purpose, the Königsteiner instruction leaflet (Königsteiner Merkblatt) recommends among other items the SISI test. Patients/methods. The results of the SISI test at 1 and 4 kHz were analysed for 100 expert opinions of noise (200 ears). Results. 10% of the subjects showed at 1 and 4 kHz a positive and 44% a negative result. At 1 kHz, 46% indicated a negative result and at 4 kHz a positive result. In the group with a negative SISI test at both frequencies, 74% demonstrated characteristics of pseudohypacusis. There was no correlation between a retrocochlear hearing disorder and a negative SISI test. Conclusions. Our analysis demonstrated that the negative SISI test is more often evidence of pseudohypacusis rather than a retrocochlear disorder. Consequently, the validity of a negative SISI test is limited.     

Stellenwert eines Ernährungsscores bei Patienten mit fortgeschrittenen Karzinomen im Kopf-Hals-Bereich

Background and objective. Patients with advanced head and neck cancer often suffer from malnutrition even before the start of therapy. Hence, the demand for nutritional support increases particularly before and during radiochemotherapy. Though nutritional therapy has been shown to substantially improve individual outcome, neither the criteria for patient candidacy nor the indications for therapeutic intervention have been established. We performed a retrospective analysis to determine the indications for nutritional support and to evaluate the benefits of measures actually taken against malnutrition before and during radiochemotherapy as well as perioperatively. Patients/methods. Data taken from a prospective study for the evaluation of oral mucositis during radiochemotherapy was analysed retrospectively. To calculate the indication for nutritional support, a nutritional scoring system (Hackl) was employed for the first time, which contained biochemical and anthropometric parameters as well as the period of starvation. The results were then compared to a nutritional support program implemented by the subjective examinations of the attending physician. Results. Changes in body weight and body mass index (BMI) remained the most impressive parameters. Catabolic metabolism developed preoperatively and a significant loss of whole-body protein followed surgical therapy. Clinically, the results of the nutritional score correlated with the observation of malnutrition. Furthermore, our findings suggest that nutritional therapy was commonly delayed until late in the clinical course. Conclusion. The results indicate the necessity of objective and reproducible diagnosis and control of malnutrition. The scoring system used may provide a useful and yet simple tool for assessing individual indications for timely nutritional support.     

91 dB Hörverlust – die Schwelle zum “Cochlear Implant”?

Background and objective. Recent indications for cochlear implant in children are bilateral total cochlear deafness and an age of 2 or more. Reports on successful implantations in adults with residual hearing pose the question of whether this indication might be expanded to children with residual hearing. Patients/Methods. In a retrospective analysis of 106 hearing-impaired children with binaural amplification, we were able to ask parents in 90 cases about their children's education. The pure-tone average of the frequencies of 1–4 kHz was correlated to education. Results. The results showed that all children except one with a pure-tone average of ≤90 dB could successfully attend regular school or kindergarten. However, those with a pure-tone average of ≥91 dB had to be educated in special units for children with impaired hearing. Conclusions. Our results indicate that amplification in children with profound hearing loss (pure-tone average ≥91 dB) is not sufficiently effective to enable them to attend regular schools or kindergarten. We conclude that the only chance to integrate these children into the world of hearing might be cochlear implantation.     

Tracheal ruptures in endotracheal intubation. Diagnosis and therapy

Background. Tracheal ruptures are most frequently the result of a blunt trauma to the thorax or of forced intubation. They represent a rare, but life-threatening complication that requires immediate help. Methods. The resulting pneumothorax and the skin/mediastinal emphysema are the most prominent clinical signs. Injuries of the tracheobronchial tract should be diagnosed endoscopically and treated surgically immediately after the trauma. Results. The present paper reports on three cases of tracheal ruptures after forced intubation which could be successfully managed by tracheostomy and subsequent reconstruction of the defects. The postoperative care of the patients is critically discussed.