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.     

Tongue base reduction with radiofrequency energy in sleep apnea

Background and objective. Tongue base reduction with temperature-controlled radiofrequency for the treatment of obstructive sleep apnea syndrome is a minimally invasive technique. Repeated application leads to a progressive shrinking of the tissue. Patients and Methods. In our study, we summarize the experiences gained from 100 tongue base reductions and compare them with the pilot study that was recently published. An intensified treatment scheme was used with higher amounts of energy applied per treatment session. Visual analogue scales were used for the assessment of postoperative pain and functional parameters. Regular follow-up visits were scheduled to evaluate postoperative complications. Results. Postoperative pain was mostly mild or moderate. Paraoperative complications were not observed. The overall rate for postoperative complications was 8%, with 2% mild and 5% moderate complications. One severe complication – a tongue base abscedation – was observed. Using para- and postoperative antibiotic prophylaxis reduced the rate of complications. Functional parameters such as taste or swallowing were not affected. Conclusions. Our results underline the safety of the procedure and demonstrate the minimal para- and postoperative morbidity. The increased amount of energy applied per session has not led to an increase in postoperative morbidity.     

Sense of smell before and after functional esthetic rhinoplasty

Background. The aim of the present study was to determine possible changes in olfactory threshold after functional and esthetic nasal operations and to evaluate whether these changes were recognized by the patients. Methods. The study included 41 patients before and after nasal surgery (septoplasty, septorhinoplasty). Nasal airway resistance, olfactory thresholds, and subjective symptom scores were evaluated and compared pre- and postoperatively. The mean follow-up was 5.4 months. Olfactory performance was assessed using the Sniffin' Sticks. Results and conclusions. The postoperative values in the screening test for olfactory sensitivity were not significantly different from those before nasal surgery. Nasal ventilation was improved postoperatively in all patients, assessed by determination of nasal airway resistance and subjective symptom scores. Besides an increase in nasal ventilation, functional and esthetic nasal operations can lead to improvement of olfactory function. The rarely seen postoperative increase in olfactory threshold does not seem to be subjectively recognizable by the patients.     

Tracheotomie oder geplante Nachbeatmung nach Operationen bei Patienten mit OSAS

Background

Patients suffering from obstructive sleep apnea syndrome (OSAS) and obesity have an elevated risk of postoperative complications independent of each other. Within the framework of expert opinions for courts the question arose whether postoperative prolonged intubation or tracheotomy are standard routine approaches which are to be carried out in the normal course of operations on patients with OSAS.

Material and methods

A search of the literature was performed using PubMed, Web of Science, Scopus, EMBASE, the Cochrane database of systematic reviews and the Cochrane central register of controlled trials. Furthermore, 78 German otorhinolaryngology (ENT) departments participated in a nationwide survey.

Results

The results of the survey showed that after normal complication-free surgery planned postoperative prolonged intubation is not performed in the majority of ENT departments and no department performs a tracheotomy. In contrast, the standard approach for patients with OSAS and obesity who undergo two-level surgery is intubation and subsequent monitoring without ventilation for the first postoperative day. In the literature no evidence of a scientific basis for carrying out prolonged intubation or a tracheotomy could be found.

Conclusion

Neither tracheotomy nor prolonged intubation are standard procedures for OSAS patients with obesity after complication-free surgery.     

Spondylophytäre Atem- und Schlafstörungen

Background. Cervical osteochondrosis is a rare differential diagnosis leading to dysphagia, inspiratory stridor and obstructive sleep apnea syndrome (OSAS). Patients and methods. We report six cases of patients with episodes of neck pain (n=6), pain reflected to the arm (n=1), sleep apnea (n=5), inspiratory stridor (n=3) and/or unclear dysphagia (n=6), who presented between 2000 and 2003 at the Römerwallklinik Mainz and the university hospitals of Mainz and Cologne. None of these patients had symptoms of spinal or radicular compression. All underwent otorhinolaryngological and radiological examination followed by excision of anterior spondylophytes and intervertebral fusion. One patient required immediate tracheotomy due to perforation of the pharyngeal wall associated with severe supraglottic swelling. Results. All patients were free of inspiratory stridor postoperatively. Symptoms of dysphagia disappeared in four patients and were reduced in two. Three of five patients were free of apnea. OSAS had improved in two. Neck pain was eliminated in four cases and markedly improved in two cases. Conclusions. In case of symptoms of pharyngeal compression and OSAS, a vertebragenic cause should be considered.     

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.     

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.     

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.     

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.     

EDV-gestützter Aufbau eines interdisziplinären landesweiten Hörscreenings im Saarland

Background. Despite many recommendations and obvious advantages universal auditory screening in new-born children is only beginning to be implemented in the German health system. Method. We report on a multistage screening project based on otoacoustic emission measurements. One of the major disadvantages of such programs is the comparatively low specificity of otoacoustic emission measurements which leads to the need for a large number of remeasurements. Thus, the organisation of follow up screening failures is one of the most important factors that influence the effectiveness of screening programs. An additional problem is a drop-out rate which can be as high as 30% of the children that have to be retested. Results. In our program we tried to solve these problems by combining primary screening in maternity wards with retesting by paediatricians using the routine examinations of children (U3 and U4) that are done for almost 100% of German babies. In addition, the data from the children that were screened and that have to be screened are transferred to a central data management system. Conclusion. Using this system, the follow up of any individual child can be monitored until a hearing loss has been diagnosed or excluded. Therefore early therapy of children with impaired hearing is possible and psychological and social defects can be avoid.     

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.     

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.     

Passagere Koniotomie im Airway-Management

Background

Extended tumors of the oral cavity, pharynx or larynx can severely compromise the performance of a necessary endotracheal intubation. Both transnasal fiberoptic intubation under spontaneous breathing as well as tracheotomy under local anesthesia require a great deal of cooperation from the awake patient. In cases with dyspnea due to a recurrent tumor the situation is much more difficult. These patients are often in a reduced general condition, show a lack of cooperation and often have postoperative or radiogenic scars of the pharyngeal and laryngeal structures.

Methods and patients

In response to these problems cricothyrotomy was performed in 16 selected patients under local anesthesia. Analgesia and sedation had been adapted to the needs of the individual patient. The cricothyrotomy was performed alternately by an anesthesiologist and an ENT surgeon. General anesthesia has been carried out immediately after secured ventilation and oxygenation had been determined.

Results

In all patients except one the airway was finally secured by tracheotomy and the larynx incision was closed in all cases. The possibility of conventional intubation was judged retrospectively by the anesthesiologist concerned and was found to be simple in one case and nearly impossible in 10 cases. There were no complications due to the surgical procedure apart from a brief episode of disturbance in wound healing and the potentially life-threatening situation of cannot ventilate-cannot intubate could be avoided.

Conclusions

In selected cases with extended tumors of the upper airway, temporary cricothyrotomy is an effective and convenient procedure to secure the respiratory tract.     

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.     

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.     

Differential diagnosis and management of retropharyngeal space-occupying lesions

Background. Diseases of the retropharyngeal space place high request on the diagnostic and therapeutic knowledge of the otorhinolaryngologist. Methods. Under consideration of six own cases and of all other published case reports, this inhomogeneous symptom is analysed systematically. Results. Commonly, these alterations of the retropharyngeal space are observed incidentally during routine throat examination or in patients suffering from dyspnoea, dysphagia, dysphonia, sleep apnoea syndrome or neck pain. Six own cases show the very inhomogeneous aetiology (retropharyngeal abscess, lipoma, malignant schwannoma, sarcoidosis, aberrant internal carotid artery, Forestier disease). Therefore, before surgery, a sufficient radiologic diagnosis (lateral neck radiography and CT or MRI respectively) is necessary to avoid grave complications (injury to the cervical spine, the brain, the spinal cord or the internal carotid artery). A tissue sample can be obtained by the transoral approach while the lateral cervical approach seems to be the better way to treat a retropharyngeal abscess. Conclusion. Because of the very different aetiology of retropharyngeal space diseases the therapy finally depends on the definite diagnosis.     

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.     

Funktionelle und ästhetische Ergebnisse nach osteoplastischen Stirnhöhlenoperationen und Profilplastiken über bitemporalen Bügelschnitt

Background and objective. The majority of inflammatory frontal sinus diseases requiring operative intervention can now be managed successfully by endonasal surgery. In problematic cases, however, optimal exposure of the entire frontal sinus and possibly complete mucous membrane removal combined with sinus obliteration must be achieved. In these cases, external frontal sinus surgery is indicated. Patients/Methods. The operative approach and findings of 35 osteoplastic sinusotomy operations and 5 forehead reconstruction operations with porous polyethylene are reviewed. Median follow-up was 3.7 years, ranging from 1 to 7 years. Indications for surgery were trauma (12), infections (8), tumors (11), muco- or pyoceles (4), and frontal deformities (5). Results. The overall functional and esthetic result was excellent. No recurrent infection was noted. None of the patients have required revision surgery so far, and no serious complications occurred. Abnormal forehead sensation was reported by 12 patients (30%). Temporary double vision was described in 3 cases (7.5%). Conclusions. Due to optimal sinus exposure and advantageous incision, osteoplastic frontal sinusotomy leads to excellent functional and esthetic results. Porous polyethylene demonstrates superior material properties and seems to be, in comparison with other implants, the current material of choice in frontal reconstruction.     

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.