Incidence and localization of abnormal mucosa findings in patients consulting ENT outpatient clinics and data analysis of a cancer registry

For patients without symptoms and at risk, there is no established early detection program to discover carcinomas of the upper aerodigestive tract in the sense of secondary prevention. Such type of prevention seems even more desirable because the chances for a cure and the quality of life are strongly dependent on the stage of the tumor and the time of the initial diagnosis. Six hundred and eight patients without symptoms but at least one of the self-reported risk factors "smoking", "alcohol consumption" or "reflux" were examined with an endoscope or an optical microscope for pathological findings in the upper aerodigestive tract once a year. In addition, the incidence of malignancies of the upper aerodigestive tract between 2001 and 2010 was determined through the Cancer Registry of Schleswig-Holstein. Tissue samples were taken from 18 of the 608 patients. Eleven patients (1.8%) had a squamous cell carcinoma. Another patient suffered from non-Hodgkin's lymphoma and one from larynx tuberculosis. The ratio of detected malignancies in the oral cavity and the oropharynx on the one hand and the hypopharynx and larynx, which can only be examined by endoscopes, on the other hand were in our cohorts and in our survey according to the cancer registry was 5/6. The above-described methods allow examining risk patients easily and safely. According to current publications, the ratio of the found malignancies exceeds the expected ratio significantly, which presumably was caused by the examination targeting patients at risk. Due to the expanded examination area using optical instruments more than doubles the rate of discoverable malignancies compared to the limitations posed by the examination of directly visible areas of the oral cavity of the oropharynx.

[Trying to unravel an unresolved issue in regenerative medicine: gene expression profiling of MSCs]

BACKGROUND

Mesenchymal stem cells (MSCs) are adult fibroblastoid progenitor cells. Because of their immunoregulatory properties and their so-called trophic effects, MSCs play an important role in tissue regeneration, inflammation and trauma. Tissue trauma and challenge, for example during radiotherapy or infection, result in the release of so-called "danger molecules", which may be derived from dying cells or incoming pathogens. The molecular response of MSCs to this tissue stress remains largely elusive.

MATERIAL AND METHODS

In this study we examined the cell biological response of MSCs derived from human parotid glands (pgMSCs) and used bacterial endotoxin as a model of tissue stress and inflammation. PgMSCs from 3 donors were isolated, expanded and tested for classical tri-lineage plus myogenic differentiation. The cell biological response to the model "stressor" endotoxin was examined by low density gene expression arrays.

RESULTS

Through immunofluorescence and immunohistochemistry we were able to proof osteogenic, adipogenic, chondrogenic, and myogenic differentiation potential characteristic for stem cells. In vitro, gene expression analysis showed a characteristic modulation of MSCs after stimulation with endotoxin Lipopolysaccharide (LPS). Specifically, receptors and ligands typically involved in immune regulation, such as interleukins, TGF-β, tumor necrosis factors (TNF), and toll-like receptors (TLR), were regulated.

CONCLUSION

Our study elucidates some key functions and molecules, which are regulated in MSCs during tissue stress and inflammation. A thorough understanding of their cell biological function will aid future rationale therapeutic application of MSCs.

[Analysis of quality of life outcome for nasopharyngeal carcinoma patients after treatment]

BACKGROUND

This retrospective study analysed patient characteristics and quality of live (QoL) for patients with nasopharyngeal carcinoma (NPC) after treatment.

MATERIAL AND METHODS

A cross-sectional investigation was conducted to assess the QoL of 20 NPC patients with cancer-free survival of more than one year, which were treated with radiotherapy (RT) or chemoradiotherapy (RCT) during the period 2001-2009 at the University Hospital Bonn, Germany. The QoL was assessed by the FACT-NP (functional assessment of cancer therapy-nasopharyngeal) questionnaire.

RESULTS

The median age of the patients was 57 ± 13 years and the male/female ratio was 2.33/1.3 (15%) patients were treated with RT and 17 (85%) with RCT. The global QoL was good in our patients. Xerostomia, chewing, decrease of gustatory sense, discontent with sexual life and ear problems were of major concern with the majority of patients and affected the QoL negatively. Pain, lost of working ability, emotional distress, or family problems were no significant factors.

CONCLUSION

The expected reduction of QoL after treatment must be explained in detail to the NPC patient. The integration of the family and partner, an antidepressant therapy or psycho-oncological support can be useful and necessary.

Recurrence rate, time to progression and facial nerve function in microsurgery of vestibular schwannoma

OBJECTIVE

Recurrence rate, time to progression, and facial nerve function were analysed by comparing patients with complete and near total tumor removal after suboccipital craniotomy for vestibular schwannoma surgery.

METHODS

From 1996 to 2004, 118 patients with vestibular schwannoma were operated with an interdisciplinary approach. Fifty patients fulfilled the inclusion criteria and were included in the study. Progression was defined as an increase of ⩾2 mm in the largest diameter in the magnetic resonance imaging. Preoperative tumor size, facial nerve function estimated using the House-Brackmann score (HBS), time to progression, and recurrence rate were analysed and related to the extent of resection.

RESULTS

In 28 cases (group I), a capsular remnant was left. In 22 cases (group II), tumor removal was complete. In group I, nine patients (32·1%) showed progression. In group II, two patients (9·1%) developed a recurrent tumor, no significance (P = 0·085). In groups I and II, 53·6 and 59·6% had a good function of the facial nerve (HBS I+II), 28·6% in group I and 13·5% in group II had a moderate disturbance (HBS III+IV), and 17·9% in group I and 27·7% in group II had a poor function (HBS V+VI). There was no significant difference between median preoperative tumor size and facial nerve function within patients with HBS III and IV.

CONCLUSION

Complete tumor removal may be associated with a risk of functional loss, whereas near total tumor removal may be associated with a higher risk of progression.

[Prevalence of abnormal mucosal findings in patients in HNO practices]

OBJECTIVE

To date, no secondary prevention program is in place for patients carrying an increased risk for developing head and neck cancer (HNSCC). In terms of successful, long-term curative therapy and increased quality of life, it would be useful to detect such diseases at an early stage.

PATIENTS AND METHODS

A total of 370 patients with at least one risk factor such as "smoking", "alcohol", or "reflux disease" and without any symptoms were examined during a 1-year period using standard HNO methods (e. g. endoscopy) for suspicious alterations of the mucosa of the upper aerodigestive tract.

RESULTS

In 13 (3.5%) of all 370 cases a biopsy was taken for further diagnosis. Squamous cell carcinoma was found in eight cases, while one further patient was suffering from non-Hodgkin lymphoma.

CONCLUSIONS

It is simple and safe to examine patients at risk of developing HNSCC by standard HNO methods. The rate of detected carcinomas is much higher than in former investigations, likely because our survey focused only on patients with specific risk factors.

Free latissimus dorsi flap for reconstruction of the anterior base of the skull

Defects resulting after resection of malignant tumors of the paranasal sinuses involving the anterior base of the skull need an adequate closure. In addition to such avital tissue as fascia lata, fat, or ceramics, in recent years we used free muscle flaps from the latissimus dorsi for reconstruction. We performed this reconstructive method in seven patients after radical tumor ##. The operation was performed in cooperation with the neurosurgeon. In three cases a transfrontal in combination with a transfacial approach was used and in four cases only a transfacial approach was chosen. The flap was tailored as a pure muscle transplant if only the base of the skull had to be repaired and the surgical cavity had to be obhiterated. In three cases a skin paddle was left on the muscle to perform a closure of the orbit and the hard palate. In four patients we performed primary reconstruction, in three cases secondary reconstruction, which was necessary because cerebrospinal fluid (CSF) leakage occurred after primary reconstruction with avital tissue in addition to insufficient pericranial flap. None of the patients with primary reconstruction developed CSF leakage. There was no free flap failure. The aim of this reconstruction is a safe closure of skull base defects to prevent infection, meningitis, brain abscess, and brain herniation.

Clinical requirements and possible applications of robot assisted endoscopy in skull base and sinus surgery

Functional Endoscopic Surgery of Paranasal sinuses (FESS) and Skull Base surgery is one of the most frequent surgeries performed at the ENT department of the Bonn University, Germany. Beside of surgical Navigation Robotic is one of the upcoming fields of Computer assisted Surgery developments. This work presents novel research and concepts for Robot Assisted Endoscopic Sinus Surgery (RASS) of the Paranasal sinuses and the anterior Skull Base containing the analysis of surgical workflows, the segmentation and modelling of the Paranasal sinuses and the anterior Skull Base and the development of the robotic path planning. An interdisciplinary group of software engineers and surgeons in Braunschweig and Bonn, Germany are approximate to solutions by a clinical and technical research program financed through the DFG (Deutsche Forschungsgemeinschaft, German research Community).

CT-based manual segmentation and evaluation of paranasal sinuses

Manual segmentation of computed tomography (CT) datasets was performed for robot-assisted endoscope movement during functional endoscopic sinus surgery (FESS). Segmented 3D models are needed for the robots' workspace definition. A total of 50 preselected CT datasets were each segmented in 150-200 coronal slices with 24 landmarks being set. Three different colors for segmentation represent diverse risk areas. Extension and volumetric measurements were performed. Three-dimensional reconstruction was generated after segmentation. Manual segmentation took 8-10 h for each CT dataset. The mean volumes were: right maxillary sinus 17.4 cm(3), left side 17.9 cm(3), right frontal sinus 4.2 cm(3), left side 4.0 cm(3), total frontal sinuses 7.9 cm(3), sphenoid sinus right side 5.3 cm(3), left side 5.5 cm(3), total sphenoid sinus volume 11.2 cm(3). Our manually segmented 3D-models present the patient's individual anatomy with a special focus on structures in danger according to the diverse colored risk areas. For safe robot assistance, the high-accuracy models represent an average of the population for anatomical variations, extension and volumetric measurements. They can be used as a database for automatic model-based segmentation. None of the segmentation methods so far described provide risk segmentation. The robot's maximum distance to the segmented border can be adjusted according to the differently colored areas.

Microscopic wire guide-based orotracheal mouse intubation: description, evaluation and comparison with transillumination

Airway access is needed for a number of experimental animal models, and the majority of animal research is based on mouse models. Anatomical conditions in mice are small, and the narrow glottic opening allows intubation only with a subtle technique. We therefore developed a microscopic endotracheal intubation method with a wire guide technique in mice anaesthetized with halothane in oxygen. The mouse is hung perpendicularly with its incisors on a thread fixed on a vertical plate. The tongue is placed with a pair of forceps between the left hand's thumb and forefinger and slightly pulled, while the neck and thorax are positioned using the third and fourth fingers. By doing so, the neck can be slightly stretched, which allows optimal visualization of the larynx and the vocal cords. To ensure a safe intubation, a fine wire guide is placed under vision between the vocal cords and advanced about 5 mm into the trachea. An intravenous 22G x 1 in. plastic or Teflon catheter is guided over this wire. In a series of 41 mice, between 21 and 38 g, the success rate for the first intubation attempt was >95%. Certainty of the judgement procedure was 100% and success rate was higher using the described method when compared with a transillumination method in a further series. The technique is safe, less invasive than tracheostomy and suitable for controlled ventilation and pulmonary substance application.

[Laser skin resurfacing and fibrin sealing as successful treatment for facial angiofibromas in tuberous sclerosis]

Tuberous sclerosis complex (TSC) is an autosomal-dominant phacomatosis that manifests with visceral harmatomas, epilepsy, and mental retardation. Paranasal angiofibromas may cause bleeding and difficulties in nasal breathing and can stigmatise the individual. When treating TSC patients, the otolaryngologist must take patient compliance and the tendency to develop malignancies into account. We report on a 34-year-old woman who was treated successfully by a combination of CO(2) laser treatment and fibrin glue. The cosmetic results were excellent.

[Proliferation and differentiation of human osteoblasts from the nasal septum in a new perfusion culture system]

BACKGROUND

Today, perfusion culture systems are mainly used to investigate cellular physiology and to cultivate three-dimensional tissue complexes. As a rule, these systems are relatively expensive and do not enable continuous microscopic monitoring of the growing cells. Simple and inexpensive perfusion culture systems have not been available up to now.

METHODS

A novel perfusion culture system was developed in which the modular components consist of a mounting apparatus for inserting various media supply systems, microdispenser pumps, and laminar-flow culture chambers, each with a culture volume of 8 cm(3). The perfusion chambers were inoculated with human osteoblast cells from the tissue culture (5,000/cm(2)) and were perfused for 10 days after adherence of the cells (0.5 ml/min). As a control group, osteoblast-like cells were cultured in identically constructed culture chambers without medium perfusion. After 10 days, the cell counts were determined in accordance with the Coulter principle. Alkaline phosphatase was measured photometrically as a characteristic for differentiation.

RESULTS

Compared with the control group, three to four times the quantity of cells were produced within 10 days in the perfusion cultures. The alkaline phosphatase values were equally high or only slightly lower, indicating that osteoblast differentiation of the cells was maintained with a higher proliferation.

CONCLUSIONS

As large a number of in vitro proliferated cells as possible is a prerequisite for clinical application of tissue engineering. By continuously supplying medium, the tested perfusion culture system enables a higher rate of proliferation of osteoblast-like cells with maintenance of differentiation. Continuous microscopic monitoring of the cultures is possible using commercially available Petri dishes.

Comparison between manual and semi-automatic segmentation of nasal cavity and paranasal sinuses from CT images

Segmentation of medical image data is getting more and more important over the last years. The results are used for diagnosis, surgical planning or workspace definition of robot-assisted systems. The purpose of this paper is to find out whether manual or semi-automatic segmentation is adequate for ENT surgical workflow or whether fully automatic segmentation of paranasal sinuses and nasal cavity is needed. We present a comparison of manual and semi-automatic segmentation of paranasal sinuses and the nasal cavity. Manual segmentation is performed by custom software whereas semi-automatic segmentation is realized by a commercial product (Amira). For this study we used a CT dataset of the paranasal sinuses which consists of 98 transversal slices, each 1.0 mm thick, with a resolution of 512 x 512 pixels. For the analysis of both segmentation procedures we used volume, extension (width, length and height), segmentation time and 3D-reconstruction. The segmentation time was reduced from 960 minutes with manual to 215 minutes with semi-automatic segmentation. We found highest variances segmenting nasal cavity. For the paranasal sinuses manual and semi-automatic volume differences are not significant. Dependent on the segmentation accuracy both approaches deliver useful results and could be used for e.g. robot-assisted systems. Nevertheless both procedures are not useful for everyday surgical workflow, because they take too much time. Fully automatic and reproducible segmentation algorithms are needed for segmentation of paranasal sinuses and nasal cavity.

[Tissue engineering of respiratory epithelium. Regenerative medicine for reconstructive surgery of the upper airways]

Reconstruction of long tracheal defects remains an unsolved surgical problem. Tissue engineering of respiratory epithelium is therefore of utmost surgical and scientific interest. Successful cultivation and reproduction of respiratory epithelium in vitro is crucial to seed scaffolds of various biomaterials with functionally active respiratory mucosa. Most frequently, the suspension culture as well as the tissue or explant cultures are used. Collagenous matrices, synthetic and biodegradable polymers, serve as carriers in studies. It is essential for clinical practice that mechanically stable biomaterials be developed that are resorbable in the long term or that cartilaginous constructs produced in vitro be employed which are seeded with respiratory epithelium before implantation. Vascularization of a bioartificial matrix for tracheal substitution is also prerequisite for integration of the constructs produced in vitro into the recipient organism. Here, the state of the art of research, perspectives and limitations of tracheal tissue engineering are reviewed.

3D endoscopic approach for endonasal sinus surgery

Functional endoscopic sinus surgery (FESS) is a minimal invasive approach adopted in case of chronic sinusitis (inflammation of the paranasal sinuses). The paranasal sinuses are hollow structures within the bones surrounding the nasal cavity. During FESS the surgeon moves the endoscope and other surgical instruments within the nasal cavity following specific paths to approach each one of the paranasal sinuses. The purpose of this study was to reconstruct these paths to access the paranasal sinuses using volumetric CT data. The results will be used for Finite Element modeling and simulations for Robot Assisted Endonasal Surgery.

[Manipulator assisted endoscope guidance in functional endoscopic sinus surgery: proof of concept]

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.

Laryngeal pleomorphic rhabdomyosarcoma

Adult rhabdomyosarcoma of the larynx is a rare disease. Two cases of laryngeal rhabdomyosarcoma of the pleomorphic subtype are presented. One case was treated with surgery followed by chemotherapy and radiotherapy, the other by surgery alone. At present 20 months after treatment the patients are without local reccurrence or metastases. The pathology of the tumor, diagnosis, and treatment are discussed.