[First experience in the thyroid and parathyroid surgery using the da Vinci® system]

BACKGROUND

Endoscopic surgery for the treatment of thyroid and parathyroid pathologies is gaining increasing attention. The da Vinci® system has been already widely used in different fields of medicine including recently thyroid and parathyroid surgery. Herein we report our first experiences in endoscopic surgery of thyroid and parathyroid pathologies using the da Vinci® system.

MATERIAL AND METHODS

8 patients presenting with struma nodosa in 6 cases and parathyroid adenomas in 2 cases have been treated using the da Vinci® system at the ENT department of Homburg/Saar University.

RESULTS

The skin incision to introduce the instruments with the da Vinci® system were axilar or at the lateral segment of the clavicle. The neurovascular structures like inferior laryngeal nerve as well as the pathologies were clearly 3-dimensional visualized in all 8 cases. No paralysis of the vocal cord was observed. All patients had in histological examination a benign pathology.

CONCLUSIONS

The endoscopic surgery of the thyroid and parathyroid gland can be performed using the da Vinci® system and offers an excellent, intraoperative, 3-dimensional visualization of the neurovascular structures. Additionally the da Vinci® system enables skin incisions within considerable distance from the thyroid and parathyroid gland.

[Complications and pitfalls in surgery of the ear/lateral skull base]

Surgery of the ear and the lateral skull base is a fascinating, yet challenging field in otorhinolaryngology. A thorough knowledge of the associated complications and pitfalls is indispensable for the surgeon, not only to provide the best possible care to his patients, but also to further improve his surgical skills.Following a summary about general aspects in pre-, intra- and postoperative care of patients with disorders of the ear/lateral skull base, this article covers the most common pitfalls and complications in stapes surgery, cochlear implantation, surgery of vestibular schwannomas, and jugulotympanal paragangliomas. Based on these exemplary procedures, basic "do's and don'ts" of skull base surgery are explained, which the reader can easily transfer to other disorders. Special emphasis is laid on functional aspects, such as hearing, balance and facial nerve function. Furthermore, the topics of infection, bleeding, skull base defects, quality of life and indication for revision surgery are discussed.An open communication about complications and pitfalls in ear/lateral skull base surgery among surgeons is a prerequisite for the further advancement of this fascinating field in ENT surgery. This article is meant to be a contribution to this process.

[Experience with individual obturators to treat nasal septum perforation]

BACKGROUND

Individual septal buttons have gained more attention during the last years. However, experiences in patients being treated by an individual septal button are limited. Therefore, further evaluation of this treatment option is needed.

MATERIAL AND METHODS

Records of 64 patients being treated by an individual septal button were evaluated retrospectively. As the silicon prints of the septum perforation were available size of the septal perforation were measured. Telephone interview were used to ask the patients about their general judgement and eff ect of the septal button on their different complaints.

RESULTS

Septumplasty in 42 patients and a trauma in 10 patients had been documented prior to treatment. In 7 patients Wegner's granulomatosis had been proven by serological and histopathological analysis. Digital manipulation and nasal drop abuses were judged to be the reason of the septal perforation in 2 patients each. In one patient the etiology remained unknown. Size of the septal perforation ranged from 7.4 to 807 mm(2). Using visual analog scale 42 patients reported to be highly satisfied. A statistically significant improvement was reported for all symptoms. Respiratory noise and nasal obstruction were improved best followed by nasal bleeding, pain and crust formation.

CONCLUSION

Treatment of septal perforations with individual septal buttons should be considered in treating septal perforations. Nasal obstruction and nasal bleeding were found to be improved best by this treatment option.

[Diagnosis and treatment of frontobasal cerebrospinal fluid fistulas]

Independent of its origin a frontobasal cerebrospinal fluid (CSF) fistula is characterized by an open connection between the intracranial space with the outside world (usually the nose and paranasal sinuses). It leads to loss of CSF and is associated with a significant risk of developing meningitis for the patient during further life. Precise knowledge of possible aetiologies, clinical symptoms, current diagnostic options and surgical strategies are essential for the detection and successful management of frontobasal CSF fi fistulas. This article summarizes aetiology and clinical signs of frontobasal CSF fistulas. Further, laboratory tests to analyse fluid samples for cerebrospinal fluid as well as radiological and endoscopic investigation methods aiming to localize a CSF-fistula are presented. Finally, surgical techniques to close a frontobasal CSF fistula are explained.

[First experience in endonasal surgery using a new 3D-Chipendoscope]

BACKGROUND

Endoscopic surgery for treatment of nasal, paranasal and anterior skull base pathologies is an established treatment modality. Available rigid endoscopes with angled views provide a 2-dimensional view with restriction of depth perception. In this study we report about our first experience with a new 3D-Chipendoscope in surgery at the nose, paranasal sinuses und anterior skull base.

MATERIAL AND METHODS

30 patients were enrolled in this study with chronic rhinosinusitis, inverted papilloma, frontal sinus mucocele, frontal sinus osteoma, chronic dacryocystitis and pituitary adenoma. All patients were subjected to standard endonasal endoscopic surgery using 3D-endoscopes.

RESULTS

Surgery was performed by the use of the 3D-endoscope in all patients. The operative handling of the 3D-endoscopes was user friendly in regard to design and weight of the endoscopes. The problem of fogging during endoscopic surgery diminishing the quality of view was not observed. Blood crusts on the endoscope tip however was able to changed the 3D-view to a 2D-view. To close positioning of the 3D-endoscopes to the surgical field reduced image quality. The visualisation of the frontal sinus was limited.

CONCLUSION

3D-endoscopic surgery is an interesting development in endonasal surgery of pathologies at the nose, paranasal sinuses and anterior skull base.

[Endoscopic frontal sinus revision following transcutaneous endoscopic puncture and diaphanoscopy]

BACKGROUND

Endoscopic revision sinus surgery in case of frontal sinus pyocele may poses a great surgical challenge for various reasons. Due to the often troublesome anatomical changes caused by prior resection and findings of scaring with new bone formation, the identification of the frontal sinus in revision surgery is frequently a challenge for the surgeon. An easy endoscopic technique for a safe endonasal identification of the frontal sinus in revision surgery is therefore of major importance.

MATERIAL AND METHODS

4 patients (3 men, 1 female) were enrolled with an acute frontal pyocele following prior open frontal sinus surgery over an external access. All patients were subjected to standard endonasal endoscopic frontal sinus surgery. The frontal sinus was endonasally approached after endoscopic transcutaneous frontal sinus puncture through the pre-existing bone defect achieving a diaphanoscopy with endonasal identification of the frontal sinus floor.

RESULTS

The external endoscopic puncture and illumination of the frontal sinus was performed in all 4 patients with a modular endoscopic system (Sinus View). A visual exploration of the frontal sinus was easily carried out after irrigation. A clear endonasal identification of the frontal sinus floor by diaphanoscopy was achieved in all patients and guided a direct opening of the frontal sinus. A stable frontal sinus drainage type IIb according to Draf was reached in all cases.

CONCLUSION

Transcutaneous frontal sinus puncture with an modular endoscope allows not only to verify frontal sinus pyocele diagnosis, but also provides the option to open the frontal sinus directly guided by the diaphanoscopy at the frontal sinus floor even in situations of complex anatomy.

Papillary tumor of the temporal bone

Papillary tumors of the middle and inner ear have been interpreted histogenetically in many ways. In 1989 Heffner proposed the endolymphatic sac epithelium as a possible origin. These rare tumors are clinically aggressive and can cause extensive temporal bone destruction. Because of this behavior, endolymphatic sac tumors (ELST) were classified as low-grade adenocarcinomas, although metastasis has not yet been documented. Two papillary neoplasms of the temporal bone are presented, which we believe are examples of adenomatous tumors arising from the epithelium of the endolymphatic sac. One was associated with a pituitary adenoma. A third case of a papillary middle ear neoplasm is described that shows histologic features similar to the other two, but it was located in the tympanum and had no connection to the endolymphatic sac. This report focuses on clinical, radiologic, and histologic findings of papillary tumors of the temporal bone with additional emphasis on modern concepts of histogenesis and aspects of differential diagnosis.

Late manifestations of traumatic lesions of the anterior skull base

The authors review their experience in detecting occult traumatic dural lesions. In a retrospective study covering the period from January 1, 1984 to December 31, 1996, 23 patients were evaluated for occult traumatic dural lesions. Clinical presentation, diagnostic work-up, and management of the dural lesions were analyzed.The clinical presentations of the previously undetected dural lesions of the anterior skull base were meningitis in eight cases, cerebrospinal fluid (CSF) rhinorrhea in eight cases, both meningitis and CSF rhinorrhea in five cases, and a pulsating swelling in the region of the right upper eyelid in one case. In another case a fracture of the posterior frontal wall was detected incidentally on the preoperative CT scan performed prior to surgery for chronic sinusitis. One patient had a CSF fistula of the lateral skull base in addition to the frontobasal fistula. The interval between trauma and diagnosis varied from 1 to 48 years. Dural lesions were localized by high-resolution CT, fluorescein nasal endoscopy, CT cisternography, and MRI. Intraoperative exposure of the dural lesions and duraplasty were possible in all cases. During the first attempt successful repair of the dural lesions was accomplished in 22 (95.7%) of the 23 patiants. Two interventions were necessary to close a CSF leak of the cribriform plate.Modern clinical and radiologic diagnostic methods should be employed to search for an occult dural lesion in patients with recurrent meningitis, meningitis caused by upper airway pathogens, or CSF rhinorrhea. The patient will remain at risk of potentially fatal meningitis until the lesion is appropriately repaired by duraplasty.

How I do it: endoscopic-microscopic anterior skull base reconstruction

Reconstruction of the anterior skull base must be secure and watertight. Failure to achieve this places the patient at risk of the development of cerebral sepsis. We have developed the technique of endonasal duraplasty and have achieved a 90% long-term success rate. In this article we described the key elements of our technique starting with radiographic and fluorescein localization of a skull base defect. The main steps in reconstruction and materials used are detailed, together with modifications of our technique for certain difficult situations and tips for success. Attention is drawn to potential pitfalls that have been identified over 25 years of clinical practice.

Mode of communication, perceived level of understanding, and perceived quality of life in youth who are deaf or hard of hearing

Given the important role of parent-youth communication in adolescent well-being and quality of life, we sought to examine the relationship between specific communication variables and youth perceived quality of life in general and as a deaf or hard-of-hearing (DHH) individual. A convenience sample of 230 youth (mean age = 14.1, standard deviation = 2.2; 24% used sign only, 40% speech only, and 36% sign + speech) was surveyed on communication-related issues, generic and DHH-specific quality of life, and depression symptoms. Higher youth perception of their ability to understand parents' communication was significantly correlated with perceived quality of life as well as lower reported depressive symptoms and lower perceived stigma. Youth who use speech as their single mode of communication were more likely to report greater stigma associated with being DHH than youth who used both speech and sign. These findings demonstrate the importance of youths' perceptions of communication with their parents on generic and DHH-specific youth quality of life.

[Lacrimal systems endoscopy with a new endoscope system]

BACKGROUND

Successful therapy of postsaccal stenosis in the lacrimal system can be done by an ENT Surgeon by endonasal dacryocystorhinostomy. It is desirable to have a good diagnostic method of the lacrimal system before undertaking surgery. This study describes the first experiences of endoscopic diagnostics of the lacrimal system with a new endoscope.

MATERIAL AND METHODS

24 patients (10 male and 14 female, between 3 and 65 years old) with epiphora and chronic lacrimal system infections were examined in the ENT Department Homburg/Saar with a 0.53 mm modular endoscope, between 11/2008 and 12/2009. The result were evaluated and analysed.

RESULTS

The endoscopic lacrimal system examination was done in all 24 patients. 8 patients with high stenosis postsaccal and purulent epiphora had an endonasal dacryocystorhinostomie. 13 patients with prasaccal stenosis or stenosis in the ductus nasolacrimalis with clear epiphora were treated with irrigation, dilatation and U-intubation. The removal of the Endoscopic dilatation was undertaken in 3 children without using bicanicular intubation.

CONCLUSION

Lacrimal system endoscopy with a modular endoscope with the possibility of interventional procedures is an efficient option in the widening diagnosis and therapy of the lacrimalm system disease. With this technique is it possible with selected patients to do interventional therapy. On the basis of the endoscopic findings an interventional therapy or an endonasal dacryocystorhinostomie can be done.

[Malignant melanoma of the lacrimal sac]

A 68-year-old woman presented with a 10-month history of right-sided epiphora, bloody tears, and medial canthal mass. Computed tomography revealed a soft tissue mass of the right lacrimal sac with widening of the bony nasolacrimal canal. External dacryocystorhinostomy with incisional biopsy confirmed the diagnosis of malignant melanoma. After staging, further therapy included orbital exenteration, lateral rhinotomy with en bloc resection of the lacrimal drainage apparatus, and adjuvant radioimmunotherapy. One year after surgery, no evidence of local recurrence or metastatic disease could be detected.

In vitro adhesion measurements between skin and micropatterned poly(dimethylsiloxane) surfaces

Micropatterned adhesive surfaces may have potential in reconstructive surgery. The adhesion performance of mice ear skin to micropatterned poly(dimethylsiloxane) (PDMS) was investigated, under in vitro conditions, and compared to flat substrates. No significant difference in separation force F was observed between flat substrates and micropatterned surfaces with pillar arrays. However, the energy necessary for separation of the substrate from the skin was sensitive to the topography. Furthermore, our results show that the force-displacement curves depended on the wetness of the skin: Highest force values were obtained for fresh skin while the forces decreased as the skin dried out. The results are encouraging for further studies on the potential of patterned PDMS in biomedical applications.

Liposarkom

With less than 100 cases described in the literature, the incidence of liposarcoma in the head and neck is very low. We report on a 54-year-old patient with a liposarcoma of the right cervical soft tissue. After complete tumor extirpation the patient underwent radiotherapy. Diagnostics, histopathological classification, therapy and prognosis of liposarcoma are discussed in this case report and review of the literature.

[Salivary gland tumor of the hard palate]

BACKGROUND

Pleomorphic adenomas of the small salivary glands are very rare and usually arise from the hard palate.

CASE REPORT

We present a female patient who was referred to our Department because of a bleeding enoral tumor, which persisted for 35 years. Histopathological examination after complete tumor excision showed a pleomorphic adenoma.

CONCLUSION

Pleomorphic adenomas are an important differential diagnosis for tumors of the hard palatine. The therapy of choice is surgical excision.

[First experiences with a new nickel-titanium piston with a shape memory feature]

BACKGROUND

The aim of this study was to describe a new stapes prosthesis with memory characteristics for wire crimping (SMart-Piston).

PATIENTS AND METHODS

This technique was used in 15 patients (mean age 43.4 years; range 28-71) undergoing routine stapes surgery. SMart-Piston prostheses with a shaft diameter of 0.5 mm and length ranging from 4.25-4.5 mm were used. Heat induced wire crimping was performed by CO2 laser in five patients, and by bipolar diathermy forceps in ten patients. In 15 patients, postoperative audiological testing was performed at an average 21.9 days and in another 10 again after 435 days following surgery.

RESULTS

The median observed air-bone-gap (ABG) postoperatively was 8.7 dB+/-7.7 dB. A total of 73% of all patients had an ABG of 10 dB or less, and all patients had less than 20 dB. In the ten patients controlled after 435 days, the ABG was 4.4 dB+/-2.4 dB. It was lower than 10 dB in all individuals.

DISCUSSION

A critical point in every stapes surgery, the prosthesis fixation to the incus, is greatly facilitated by this novel technique. Long-term results in a larger group of patients are pending.