[Experimental studies of chondrosynthesis for the larynx]

The aim of this study was to develop and investigate techniques for stabilising and reconstruction of defects in the larynx similar to osteosynthesis.

MATERIAL AND METHODS

(1) 400 extrusion forces of sutures and various screws (Howmedica) in thyroid cartilage of fresh cadavers were measured. (2) A new screw specially designed for cartilage was developed. (3) A new technique for stabilising cartilage with a screw nut made out of bone was developed.

RESULTS

The extrusion forces correlate with the calcification of the laryngeal skeleton depending on the investigated area of the thyroid cartilage and the type of suture and screws that are used, respectively. Besides the increased extrusion forces the advantages of chondrosynthesis are the possibility of axial stabilisation and of exact bridging of defects with or without implants.

[Kikuchi lymphadenitis. A contribution to the differential diagnosis of cervical lymph node swelling of unknown origin]

According to its morphological appearance, Kikuchi's disease is also called "histiocytic necrotizing lymphadenitis". This disorder was first described in Japan in 1972 as a benign lymphadenopathy of the neck. In Germany only a few cases have been reported by pathologists, whereas most clinicians are unaware of the existence of this rare disease, which can easily be mistaken for malignant lymphoma. In 1993 three cases of Kikuchi's lymphadenitis were treated at the ENT Department of the University of Lübeck. Patients' ages ranged from 15 to 30 years old. Except for cervical adenopathy, findings in blood tests, viral serology and radiological imaging were unremarkable. While fine needle aspirations were suspicious for malignant lymphoma, a final diagnosis of self-limiting "Kikuchi's lymphadenitis" was established histologically from excised lymph nodes. In our opinion early extirpation of lymph nodes and consultation of a pathologist are necessary to make a correct diagnosis without delay. Thus, in patients with Kikuchi's lymphadenitis unnecessary staging procedures and treatment can be avoided.

[Pressure-volume analysis of wound suction drainage containers and suction capacity of drainage tubes]

Four low-vacuum systems and eight high-vacuum systems were examined with special reference to the pressure-volume relations. The maximum filling volume for adequate transport of wound secretion was determined for each type. The use of a synthetic wound fluid instead of water resulted in a smaller aspiration volume. Enlargement of the tube diameter resulted in a reduced initial vacuum for the low-vacuum systems, whereas the high-vacuum systems were not affected. Normal drain tubes were compared with "Ulm drains" and silicon tubes for suction capacity. The suction maximum of normal tubes and silicon tubes was located at the proximal holes of the perforated tubes. The "Ulm drain," with perforation diameter increasing continuously to the distal end of the tube, was found to exert suction even at the more distal part of the tube. It is estimated that this tube allows locally more balanced vacuum in the wound.

[Complications of otoplasty and their treatment]

The multitude of otoplastic techniques, described in literature, which are based, as the case may be, on one of the three standard techniques for the correction of prominent ears, shows there is no single technique for satisfactory results. Hence, early and late complications can occur after otoplasty, both immediately and up to 2 weeks and later. These complications include granulomas, allergic reactions, keloids, reprotrusion as well as severe deformities with different defects, besides disturbances of sensitivity, often requiring repeat surgery. The management and treatment of the various complications are described and some reconstruction procedures are demonstrated, employing fascia, skin and cartilage to keep the damage at a minimum.

[Epidermal proliferation rate after skin expansion in the dog model]

The aim of this study was to evaluate the time course of the epidermal proliferation under the influence of skin expansion. Therefore 99 expanders were implanted in 18 beagles. The expansion times were between 2 hours and 4 months. Cells in the S-phase were marked by in vivo application of bromodesoxyuridine (BrdU). The tissue specimens were immunohistochemically stained and positive nuclei counted. The proliferation index increased markedly about 32 hours after the onset of the expansion and decreased afterwards slowly during the first week. Because the dog is the most appropriate species for experimental expansion studies (4,5) it can be assumed that skin expansion leads to a stimulation of the epidermal proliferation during the first few days also under clinical conditions. Nevertheless, the amount of skin that can be surgically used depends not only on the characteristics of the epidermal layer, but also on the dermis with its strong fibre system. Own studies published elsewhere (8) have shown that the dermal fibres react much slower to the expansion stimulus, so that even though there is an early epidermal proliferation increase new surgically applicable skin can only be produced by long-term expansion.

[Tissue expansion. Part 1: Technical and physiologic principles]

The technique of tissue expansion can now be used to prepare skin for reconstructive operations. This method has been propagated during the last 15 years, but its use has varied from great enthusiasm with exaggerated expectations to disillusion due to high complication rates. For an efficient and successful application of skin expansion an understanding of skin reactions and their control is mandatory. In this review, the biological principles of expansion, various expansion protocols and their objectives, control during the filling phase and preventive measures to avoid complications are described. For clinical use it is important that there is not one but three distinct types of expansion: an intraoperative, intermittent expansion for gentle subcutaneous skin mobilization, a short time period for expansion (between 1-2 weeks) to increase the dermal microcirculation and the "classic" prolonged period of expansion to create new skin for the reconstruction required.

[Pressure-volume analysis of wound suction drainage systems and their importance in otorhinolaryngologic surgery]

Four low-vacuum systems and 6 high-vacuum systems were examined concerning their pressure-volume relationships. For each type the maximum filling volume for sufficient drainage of wound secretions was determined. The use of a wound fluid substitute instead of water resulted in a lower aspiration volume. Enlargement of the tube diameter showed a reduction in the initial vacuum for the low-vacuum systems, whereas the high-vacuum systems were not affected. The amounts of postoperative wound fluid lost in selected ENT operations were determined. Considering the volume capacity of the wound drainage systems, the type of container can be chosen that eliminates the necessity for later bottle exchange on the wards, thus avoiding a potential risk for wound infection. The high-vacuum systems with a volume capacity of 150 or 200 ml are sufficient for parotidectomies, costal cartilage resections and reconstructions of the auricle, resulting in good postoperative wound adaptation and also preventing the need for postoperative bottle exchanges.

Adults' conceptions of everyday memory failures in others: factors that mediate the effects of target age

This study investigated young and older adults' conceptions of memory failure in others. One hundred young and 100 older adults rated memory failures in targets of 20, 40, 60, and 80 years of age as to how likely the memory failures were due to lack of effort or lack of ability. With increasing age, targets' forgetful episodes were rated as less likely to be caused by lack of effort and more likely to be due to lack of ability. A Subject Age x Target Age interaction on ability ratings showed age to be more salient for older subjects. Memory content, type of memory, subject sex, and target sex all influenced judgment of memory failure. The results support Erber's (1989) notion of a double standard in memory-failure appraisal; they demonstrated that adults' conceptions of memory include a decremental view of memorial ability with increasing age that is differentially sensitive to subject, target, and memorial variables.

Adults' conceptions of everyday memory failures in others: factors that mediate the effects of target age

This study investigated young and older adults' conceptions of memory failure in others. One hundred young and 100 older adults rated memory failures in targets of 20, 40, 60, and 80 years of age as to how likely the memory failures were due to lack of effort or lack of ability. With increasing age, targets' forgetful episodes were rated as less likely to be caused by lack of effort and more likely to be due to lack of ability. A Subject Age x Target Age interaction on ability ratings showed age to be more salient for older subjects. Memory content, type of memory, subject sex, and target sex all influenced judgment of memory failure. The results support Erber's (1989) notion of a double standard in memory-failure appraisal; they demonstrated that adults' conceptions of memory include a decremental view of memorial ability with increasing age that is differentially sensitive to subject, target, and memorial variables.

Psychiatric disorder and disability in New Zealand long-stay psychiatric patients

A study was undertaken of the prevalence of physical disease, psychiatric disorder and deviant behaviour in a sample of 137 long stay psychiatric patients at Porirua Hospital near Wellington, New Zealand. Patients were in the main male, single, middle-aged to elderly and of European descent. Schizophrenia was the most common diagnosis. Psychiatric symptoms were moderately severe, the most common being unusual mannerisms and posturing, anxiety, blunted affect, tension, unusual thought content and somatic concerns. Known physical disorders were present in 66 patients. Levels of neuroleptic medication were high and tardive dyskinesia was observed in almost 60% of patients. Frequency of deviant behaviour was low in absolute terms but nonetheless problematic. The frequency of deviant behaviour was similar to those reported for British patients.

Clinical and experimental evaluation of intermittent intraoperative short-term expansion

To assist in the closure of defects in the region of the head lack and neck, a number of surgeons recommend intermittent intraoperative short-term expansion to exploit the biomechanical properties of the skin. It was the aim of this study to assess quantitatively the amount of intraoperative "tissue gain," to analyze its origin, and to throw light on its underlying biomechanical processes. A total of 285 expansions in 5-minute intervals under a constant tissue pressure of 100 mmHg were performed on 30 patients with severe microtia. The volumes achieved were protocolled, and microcirculation was monitored with the help of a laser-Doppler flowmeter. Expanders exerting a tissue pressure of 100 mmHg for more than 80 cycles lasting 20 minutes also were employed in five dogs. Apart from determining the volumes, changes in distance between the skin tattoos and the diameter of the expander base were recorded. A volume increase of about 10 percent per hour was recorded for the human patients and an increase of about 30 percent per hour for the animals. After reaching a maximal increase in length of 15 to 20 percent, there was no further skin elongation despite increasing volumes. Instead, the expander began to move into the subcutaneous tissue so that its diameter showed a continuous increase. We can conclude on the basis of these results that the increase in volume during intermittent intraoperative short-term expansion is not caused by the proclaimed "creep" behavior of the skin.

[Ultrasonic diagnosis of the tonsillar region]

From 1989 to 1991, 126 tonsils were prospectively studied in cadavers, volunteers and patients by B-scan ultrasonography. The transducer was positioned just medial of the mandibular angle. The submandibular gland, M. digastricus, M. stylohyoideus and the tongue proved to be suitable landmarks. Normal and chronically inflamed tonsils both presented as oval structures with weak echos. Peritonsillar abscess could not be sonographically defined in 13/15 cases. Squamous cell carcinoma presented with random echos and indistinct borders. Infiltration of the base of the tongue could be safely confirmed.

[Ultrasound-controlled fine needle biopsy of pathologic space occupying lesions in the head and neck area]

We report 121 fine-needle aspiration biopsies of tumours and lymph nodes of the head and neck guided by ultrasound. The average minimal diameter of the lesions was 1.2 cm; the smallest lymph node was adjacent to the carotid artery and had a diameter of 0.4 cm. There were no complications. Of the cytological results 96% were confirmed by histology or by the subsequent clinical course.

[Benefits and limits of sonography of the masseter muscle]

A sonographic method for diagnosis, follow-up and quantification of normal and hypertrophied masseter muscles is presented. This technique lends itself to diagnosis of macroscopic structural alterations of the muscle as well as tumors in the vicinity. Functional or microscopic tissue changes like trigger points in myofacial pain-dysfunction syndrome cannot be detected sonographically.

[Stabilizing splint versus relaxing appliances in the treatment of myofacial pain. Preliminary results of a prospective randomized study]

Both stabilizing splints and relaxing appliances have been recommended for the treatment of myofacial pain. It was the goal of the present study to compare the therapeutic effect of these two types of appliances. 26 patients with myofacial pain, whose symptoms were not overshadowed by arthropathy and in whom previous physiotherapy had failed to bring about sufficient pain relief, were divided into two prospectively randomized groups. They received either a stabilizing splint or a relaxing appliance. The therapeutic effect was assessed with the aid of the patients' subjective reports and the Helkimo indices. In spite of the small number of patients the statistical evaluation of the results showed stabilizing splints to be significantly (p less than 0.03) superior to relaxing appliances in the treatment of myofacial pain.

[Non-invasive sonography and ultrasound-guided puncture of suspected malignant facial and neck masses]

102 patients with malignomas of the face and neck were examined by palpation, sonography, and in some cases also computed tomography. In 79 patients the cervical lymph nodes had to be removed surgically. Intraoperative and pathohistological findings were compared to the examination results before treatment. Sensitivity values were 100% for sonography, 85% for palpation, and 80% for CT. For a differentiation between benign and malignant space occupying lesions sonographic structures, shapes, and sizes of non-tumorous lymph nodes were compared to those of metastasizing ones. However, non-invasive sonography alone was not sufficient for a reliable diagnosis about the nature of the tumor. Therefore a first report is presented on ultrasound-guided fine needle puncture and aspiration biopsy of suspected malignant face and neck masses.

Significance of arthrography and computed tomography in the assessment of internal derangement of the temporomandibular joint

Arthrography was performed on 56 joints of 47 patients presenting with symptoms of pain and dysfunction of the temporomandibular joint. The diagnosis could be confirmed in 53 joints. In addition, there was evidence of 13 perforations and 7 joints with adhesions. In 51 of the affected joints, computed tomography (CT) was also performed to compare both methods. The same CT procedure was performed on 12 joints of patients without any joint problem. Almost consistently (88%), an arthrographically anteriorly dislocated disc was detectable in the axial CT scans. 92% of the healthy joints showed normal soft tissue structures. For CT visualization of a displaced disc sagittal reformations or primary sagittal scans are not necessary. Confirmation of possible perforations or adhesions cannot be made by CT. Comparing the advantages and disadvantages, arthrography must still be regarded as superior to CT. In some cases, however, CT is a valuable tool in assessing an internal derangement.

Ultrasonography of inflammatory soft tissue swellings of the head and neck

Experience with 107 B-scan sonographs of inflammatory soft tissue swellings of the head and neck is described, and an echomorphologic classification is proposed which consists of the following five types: edema, infiltrate, preabscess, echo-poor, and echo-free abscess. Because the clinical course of the symptoms differs significantly between the last three types, it was concluded that they represent different stages of abscess formation. A comparison of all the physical and sonographic diagnoses showed only slightly higher sensitivity for sonography. However, with regard to the specific diagnosis of abscess, the sonographic examination seemed to be superior to the clinical diagnosis.

Myofascial pain syndrome of the head and neck: a review of clinical characteristics of 164 patients

Myofascial pain syndrome (MPS) is a common but misunderstood muscular pain disorder involving pain referred from small, tender trigger points within myofascial structures in or distant from the area of pain. Misdiagnosis or inadequate management of this disorder after onset may lead to development of a complex chronic pain syndrome. A review of the clinical characteristics of 164 patients whose chief complaints led to the diagnosis of MPS revealed that these patients had (1) tenderness at points in firm bands of skeletal muscle that were consistent with past reports, (2) specific patterns of pain referral associated with each trigger point, (3) frequent emotional, postural, and behavioral contributing factors, and (4) frequent associated symptoms and concomitant diagnoses.

Chemical characterization of a rabbit leukocytic pyrogen

Crude pyrogen was obtained by stimulating 1.4 x 10(12) peritoneal-exudate leukocytes from rabbits in vitro with Escherichia coli endotoxin. A pyrogen molecule was isolated by ammonium-sulfate precipitation, polyacrylamide gel electrophoresis at pH 5.5 and 8.9, and gel filtration on Bio-Gel P-100. These procedures yielded a pyrogenic fraction which was electrophoretically and immunologically homogeneous. The pyrogenicity was 50 ng/kg of rabbit. This leukocyte pyrogen consisted of a protein with a molecular weight of approximately 14 000. Amino-acid analysis showed high amounts of glutamic acid and glycine; methionine and tryptophan were present in small quantities. Arginine was found to be the N-terminal amino acid. The molecule contained about 0.8% neutral sugar and 0.7% lipids. Its approximate isoelectric point in citrate/phosphate buffer was 4.2. The activity was lost by lyophilization and storage at - 18 degrees C for six months. The data presented here are the first detailed characterization of a rabbit leukocyte pyrogen. The properties in common to leukocytic pyrogen and interleukin 1 are discussed.

[Left ventricular relaxation and filling abnormalities in patients with HOCM and left ventricular pressure overload (author's transl)]

In order to test the hypothesis that delayed mitral valve opening (MO) with regard to endsystolic dimension (t DS-MO) is specific for hypertrophic obstructive cardiomyopathy (HOCM), LV echograms of patients with different forms of LV hypertrophy due to chronic pressure overload (CPO; aortic stenosis + arterial hypertension, n = 24) and hypertrophic obstructive cardiomyopathy (n = 24) were recorded, digitized and compared with those of normals (N :n = 28(. In patients with HOCM (93 +/- 37 ms; p less than 0.0001) and CPO (66 +/- 31 ms; p less than 0.0001) the time t DS-MO was significantly delayed compared with N (13 +/- 15 MS), due to abnormal relaxation. This prolonged relaxation time resulted in an abnormal diameter increase (delta D) during the isovolumic relaxation phase (HOCM: 4.0 +/- 2.2 MM/CPO: 3.0 +/- 1.8 mm; p less than 0.0001/N:0.6 +/- 0.5 mm) and the rapid filling phase (HOCM 7.6 +/- 2.7 mm; p less than 0.0001/CPO 9.2 +/- 2.9 mm; p less than 0.05 / N: 10.7 +/- 2.2 mm). The echocardiographical signs of an abnormal relaxation are not specific for HOCM, they can be seen in different forms of secondary LV hypertrophy and are accompanied by changes in the diastolic filling pattern.

[Vaccination complications after oral poliomyelitis vaccination (author's transl)]

A vaccination complication is only to be recognized if, taking into consideration the incubation time, the clinical picture coincides with that of spontaneous poliomyelitis. Apart from exceptional cases, virological studies are only of importance for the assessment if they are carried out in the acute or subacute stages. Only six out of more than 150 cases could be accepted as vaccination complications.

Mechanism of fever induction in rabbits

Three exogenous pyrogens (Escherichia coli lipopolysaccharide, synthetic double-stranded ribonucleic acid. Newcastle disease virus) were compared with respect to their mechanisms of fever induction in rabbits. All inducers stimulated the production of an endogenous pyrogen demonstrated in the blood as well as prostaglandins of the E group, and of cyclic adenosine 3',5'-monophosphate in the cerebrospinal fluid. The concentrations of these compounds were elevated approximately twofold as compared to the controls. Independently of the mode of induction, the fever reaction could be prevented by pretreatment with 5 mg of cycloheximide per kg, although the three fever mediators were induced as in febrile animals. Consequently, at least one additional fever mediator that is sensitive to a 30 to 50% inhibition of protein synthesis by cycloheximide has to be postulated. The comparable reactions of the rabbits after administration of different pyrogens argues for a similar fever mechanism. In contrast to fever induction there was no stimulation of endogenous pyrogen, prostaglandins of the E group, and cyclic adenosine 3',5'-monophosphate in hyperthermia as a consequence of exposure of the animals to exogenous overheating. Furthermore, hyperthermia could not be prevented by cycloheximide.

Prostaglandins in cerebrospinal fluid of patients during various infectious diseases

Concentrations of prostaglandins of the E and F series were estimated by radioimmunoassay in cerebrospinal fluid (CSF) of 30 febrile patients (infants and adults) and of 19 afebrile, adult patients. In CSF of all feverish patients with meningitis, pneumonia, or pyelonephritis, concentrations of prostaglandins of the E series were about twice higher than those of the afebrile subjects. In contrast, concentrations of prostaglandins of the F series remained largely unchanged during fever. In accord with the results of animal experiments prostaglandins of the E series seem to act as mediators of fever during infectious diseases also in man.

Inhibition of Newcastle disease virus-induced fever in rabbits by cycloheximide

Pretreatment with cycloheximide prevents virus-induced fever in rabbits. Compared to the febrile control animals, CH-pretreated afebrile animals exhibit similar concentrations of endogenous pyrogen in the blood and of prostaglandins of the E-group and adenosine 3', 5'-cycle monophosphate in the cerebrospinal fluid. The fever response seems to involve one or several additional so far unknown mediators which are sensitive to cycloheximide.

Adenosine 3',5'-cyclic monophosphate in rabbit cerebrospinal fluid during fever induced by E. coli-endotoxin

In rabbit cerebrospinal fluid during fever induced by E. coli-endotoxin adenosine 3',5'-cyclic monophosphate concentrations are about 2-fold higher in comparison to normal values. In addition to prostaglandins of the E series adenosine 3',5'-cyclic monophosphate might act as another mediator in the genesis of fever during infectious diseases.