[Experience with laryngotracheal reconstruction in subglottic stenosis in a 30 years time period]

BACKGROUND

Severe subglottic stenosis is a difficult condition to manage. It can be treated by laryngotracheal reconstruction or cricotracheal resection.

PATIENTS AND METHODS

In this retrospective study the experiences for treatment of isolated subglottic stenosis in 37 patients (age: 3-78 years; stenosis grading: 20 x grade II, 13 x grade III, and 4 x grade IV) by laryngotracheal reconstruction in a 30-years experience are presented.

RESULTS

In 33 out of 37 patients (89.2 %) a sufficient subglottic patency (postoperative endoscopic finding: stenosis less than 30 %) was achieved by laryngotracheal reconstruction. However, 5 patients of this series had required revision of laryngotracheal recontruction and in 22 patients endoscopic removal of granulation tissue had been performed. Sufficient widening of the subglottic space had been possible in all grade II stenosis (20/20), in 11 out of 13 patients with grade III stenosis, and in 3 out of 4 patients with grade IV stenosis. In one child an accidental decannulation occurred and due to asphyxia an apallic syndrome developed.

CONCLUSIONS

Even through laryngotracheal reconstruction is a demanding surgical technique requiring great experience it is an effective option for treatment of subglottic stenosis less than 90 %. For severe subglottic stenosis (> 90 %) treatment by laryngotracheal reconstruction is possible and should be considered if mobilisation of the trachea by scar tissue is suited to be worse or to extended cricotracheal stenosis is present, both being not good candidates for cricotracheal resection.

[Temporary sensory hearing deficits after ear surgery--a retrospective analysis]

BACKGROUND

Temporary and persistent threshold shifts can occur after ear surgery. So far, only few studies deal with temporary sensory hearing deficits after ear surgery.

PATIENTS AND METHODS

In a retrospective study, thresholds at 500 Hz, 1000 Hz, 2000 Hz and 4000 Hz were analysed in 393 patients (125 x mesotympanal chronic otitis media, 164 x cholesteatoma, 44 x tympanosclerosis, 60 x otosclerosis) before, the first 4 days and 3 weeks after ear surgery to evaluate possible temporary threshold shifts.

RESULTS

Analysis of all patients in total proved statistically significant slight temporary threshold shifts of up to 7 dB at 2000 Hz (postoperative day 1 to 3) and at 4000 Hz (postoperative day 1 and 2). Use of a drill caused a statistically slight temporary threshold shift only at 2000 Hz at the first postoperative day (4.2 dB). In cholesteatoma surgery with preparations at the ossicular chain a statistically significant slightly higher threshold level was found in all postsurgical evaluations at 500 Hz. Removal of scars or granulation tissue attached to the ossicular chain was not associated with an elevation of threshold levels.

CONCLUSION

Slight temporary threshold shifts can be observed at 2000 Hz and 4000 Hz after ear surgery. Use of the drill and preparation at the ossicular chain usually results in no significant sensory hearing deficit.

Das Styloidsyndrom und seine Behandlung

BACKGROUND

An elongation of the styloid process or an ossification of the stylohyoid ligament can be the cause for a styloid syndrome and may lead to craniocervical pain, globus sensation and dysphagia. Pathophysiologically, the styloid syndrome is related to an irritation of the surrounding nerves, the carotid artery or the pharyngeal mucosa. There are various alternatives for its treatment.

PATIENTS AND METHODS

This study analyzed retrospectively the data of eleven patients, who were treated for a styloid syndrome. All patients were placed on a stepwise therapy plan, which began with a medicamentous treatment, followed by a surgical treatment, if the problems persisted. The surgical approach included a transoral styloid fracture and/ or a surgical styloid shortening, which was carried out either transorally or transcervically.

RESULTS

Three of the eleven patients presented no complaints after the medical treatment and did not require any further therapy. In two out of five patients, transoral fracturing of the styloid was successful. Six patients underwent surgical resection of the styloid process. In five cases a transoral route was used and in one cases a transcervical route. Postoperatively, four patients were free of symptoms and did not present any functional deficit. Two patients experienced severe complications with an ipsilateral medial cerebral artery infarction. These were related to a dissection of the internal carotid artery (ICA) in one case, and an arrosion bleeding of the ICA after the formation of an abscess of the parapharyngeal space in the other case.

CONCLUSION

A stepwise therapy of the styloid syndrome including medicamentous treatment, transoral styloid fracture and resection of the styloid process has proven to be of value. If the styloid process can be palpated submucosally, a transoral resection may be chosen. However, using this route, the possibility of severe complications has to be taken into consideration, such as injury of the internal carotid artery.

[Individual silicon applicator for nasopharyngeal brachytherapy]

BACKGROUND

Beyond surgery, conventional radiation therapy, and chemotherapy brachytherapy may enrich treatment of primary, residual, or recurrent head and neck cancer. Nasopharyngeal cancer is a proper indication for intracavitary brachytherapy which can be performed using a commercial applicator system or an individual applicator.

METHODS AND PATIENTS

Technique for manufacturing an individual nasopharyngeal silicon applicator and its experiences in 3 patients (2 times brachytherapy in treatment regime of primary nasopharyngeal cancer, 1 time for nasopharyngeal lymphoma treatment) are presented.

RESULTS

Under general anaesthesia in all 3 patients nasopharyngeal imprinting after placement of two suction tubes was performed with shore 12 silicon and followed by manufacturing the individual silicon applicator with two included tubes after plaster cast of the imprinting form has been performed. This silicon applicator enabled safe endocavitary brachytherapy using the high-dose-rate-afterloading-method. Tumor control was achieved in all 3 patients.

CONCLUSIONS

The presented individual silicon applicator is suited for intracavitary brachytherapy of the nasopharynx being an valuable contribution in the primary treatment regime of nasopharyngeal cancer.

[Cell transplantation for a CSF-fistula. Experience with fibrin glue and fibroblasts]

BACKGROUND

In the present study we investigated the culturing of fibroblasts on fibrin glue embedded suture nets, to analyse the possibility of using these components in a suture application technique for the closure of a CSF-fistula.

RESULTS

Placement of centrally perforated dura pieces on fibrin glue coated surfaces resulted in cellular migration from the dura borders into the defect, resulting in a complete cellular closure of the perforation. Inversion microscopic follow-up during culturing and the Alamar blue-essay found strong growth stimulation for oral mucosa fibroblasts on fibrin glue coated surfaces by insulin and FGF. Three-dimensional fibroblast growth was observed along the suture lines in the presence of fibrin glue.

CONCLUSIONS

Fibrin glue is an attractive extracellular matrix for cellular migration from the dura which is suited to fibroblast culturing in suture nets. Our findings support the idea of achieving closure of cerebrospinal fluid fistulas by suture application of autologous fibroblasts and fibrin/thrombin preparations as a realistic future goal.

Chromosomale Alterationen beim juvenilen Angiofibrom

INTRODUCTION

Despite their benign histological appearance, juvenile angiofibromas, which occur mainly in adolescent males, have a locally aggressive growth pattern. beta-catenin-mutations represent their only known genetic abnormality.

MATERIAL AND METHODS

Angiofibroma tissue from seven patients was available for comparative genomic hybridization (CGH).

RESULTS

In six out of the seven angiofibromas, CGH detected various abnormalities on 18 different chromosomes. Frequent chromosomal gains were observed on chromosomes 4q, 6q, and 8q. In four out of seven angiofibromas a complete loss of the chromosome Y was detected.

CONCLUSIONS

CGH is a suitable method for the examination of angiofibromas for genetic alterations. Considering the sex distribution of this neoplasm, the frequent loss of chromosome Y is of particular interest.

[Malignant transformation of a tubular adenoma in the paranasal sinuses?]

BACKGROUND

Whereas a tubular adenoma is a unique finding within the paranasal sinuses, intestinal adenocarcinomas are especially in patients with long-term exposure to wood dust, common tumours in this location.

CASE

In a 65 year old joiner endonasal sinus surgery performed to treat suspected chronic pansinusitis brought up by chance the histological finding of a tubular adenoma. As the patient at first refused surgical revision, but magnetic resonance imaging during follow-up revealed evidence for a space occupying lesion affecting the ethmoid and sphenoid sinuses revision surgery took place one year later. Histopathological evaluation now found a papillary adenocarcinoma. Clinical follow-up and magnetic resonance imaging one year after second surgery found no evidence for tumour recurrence.

CONCLUSIONS

Progression of a tubular adenoma to an adenocarcinoma like in the adenoma-carcinoma model well known for colorectal carcinomas has so far not been observed within the paranasal sinuses. But, an adenocarcinoma already present at the time of first surgery can not be ruled out completely in the presented case as histopathological evaluation may have failed to detect an adenocarcinoma in the available specimens after first surgery. Either malignant transformation of a tubular adenoma had occurred or proof of an adenocarcinoma has failed with misdiagnosis of a tubular adenoma. A tubular adenoma as well as an adenocarcinoma require complete resection and careful clinical and radiological follow-up to avoid adenocarcinoma development from a tubular adenoma or to detect an adenocarcinoma by histological evaluation of the whole specimen.

[Expression of members of the cadherin-/catenin-protein family in juvenile angiofibromas]

BACKGROUND

Angiofibromas are benign, but locally aggressive tumors occurring nearly exclusively in adolescent males. Pathogenesis of this fibrovascular neoplasm is still unknown. Detection of beta-catenin gene mutations and immunohistochemical localization of beta-catenin only in the nuclei of stromal cells has been proposed as evidence for the stromal cells to be the neoplastic cells in angiofibromas (Abraham et al., 2001).

METHODS

Paraffin embedded tissue of 13 angiofibromas was analysed immunohistochemically for expression of E-cadherin, N-cadherin, alpha-catenin, beta-catenin and gamma-catenin.

RESULTS

In all angiofibromas stromal cells showed in their cytoplasm and their nuclei strong immunoreaction for beta-catenin. In 10 out of 13 angiofibromas strong immunoreaction was also observed in endothelial cells covering the irregular lined vascular spaces. While gamma-catenin was detected in 7 out of 13 angiofibromas in the stromal cells and endothelial cells, N-cadherin was found only in the stromal cells in 8 out of 13 angiofibromas. No significant immunoreaction in angiofibromas was seen for E-cadherin and alpha-catenin.

CONCLUSIONS

Proof of strong beta-catenin-expression in stromal cells and endothelial cells stress possible importance of the APC/beta-catenin-pathway in angiofibromas, but gives no certain evidence for the assumption that stromal cells may be the neoplastic cells. As beta-catenin can increase sensitivity of the androgen receptor, it may be assumed that the increased beta-catenin-expression in angiofibromas is involved in the typical growth stimulus of this tumor in adolescent males.

[Life-threatening displacement of a tracheostomy tube in a patient with severe angiotensin-converting enzyme inhibitor-induced angioedema]

Angioedema of the lips and the tongue with pharyngeal and laryngeal involvement caused by angiotensin-converting enzyme inhibitors (ACEI) is rare but can cause severe airway compromise and even death due to suffocation. We present the case of a 83-year-old woman with a life-threatening displacement of a tracheostomy tube followed by tension pneumothorax after initial successful treatment of such an airway obstruction by emergency tracheostomy. This case highlights the hazards of tracheostomy tube displacement and is a reminder that where concern of tube dislodgement exists and especially when the possibility of orotracheal intubation is lacking due to upper airway obstruction or difficult airway, permanent epithelized tracheostomy should be performed early to ensure safe and fast tube replacement at any time.

[Aetiology of Angiofibromas: Reflection on their Specific Vascular Component]

BACKGROUND

Even though numerous theories have speculated either on the vascular or fibrous tumour component as tissue of origin, aetiology of angiofibroma still remain unclear. Histological investigations recently led Beham and coworkers to the assumption that angiofibromas have to be considered as vascular malformations.

METHODS

After giving a literature review of the various theories on tumour origin the proposal to consider angiofibromas as vascular malformations is discussed on an embryological base. Taking typical clinical features of the tumour and knowledge of vasculogenesis into account a new explanation for origin of the vascular tumour component is presented.

RESULTS

The vascular component of angiofibromas can be explained embryologically due to incomplete regression of the first branchial arch artery (vascular atavism). This vessel arises regularly between embryological day 22 and 24 and recedes during regular development completely until delivery via temporary formation of a vascular plexus. In the late stages of embryological development remnants of the plexus are found at the area of the sphenopalatine foramen, the typical site of angiofibroma origin. Incomplete regression of the vascular plexus of the former first branchial arch artery may form the vascular component of an angiofibroma arising due to growth stimulation at the time of adolescents.

CONCLUSIONS

Incomplete regression of the first branchial arch artery presenting an atavism is suited to explain the vascular tumour component of angiofibromas considering main tumour characteristics (origin in the posterior nasal cavity close to the sphenopalatine foramen, main blood supply from the maxillary artery with possible feeders arising from the internal carotid artery). Our embryological contributions support to define angiofibromas as vascular malformations.

Magnetic resonance imaging in patients with sudden hearing loss, tinnitus and vertigo

OBJECTIVE

The etiopathogenesis in audiovestibular symptoms can be elusive, despite extensive differential diagnosis. This article addresses the value of magnetic resonance imaging (MRI) in analysis of the complete audiovestibular pathway.

STUDY DESIGN

Retrospective evaluation.

SETTING

Tertiary referral center.

PATIENTS

Consecutive sample of 354 patients (mean age 49 years, range 8 to 86 years) with audiovestibular disorders.

INTERVENTION

Contrast-enhanced MRI of the head with thin-slice investigation of the inner ear, internal auditory meatus, and cerebellopontine angle.

MAIN OUTCOME MEASURE

All MRIs were evaluated by experienced independent investigators. Statistical analysis was performed using the Statistical Package of Social Sciences data analysis 9.0.

RESULTS

MRI abnormalities were seen in 122 of 354 patients (34.5%). The MRIs revealed the following: 4 pathologic conditions (1.1%) of the cochlea/labyrinth, 23 abnormalities (6.5%) at the internal auditory meatus/cerebellopontine angle, 12 pathologic lesions (3.4%) that involved the central audiovestibular tract at the brainstem, 78 microangiopathic changes of the brain (22%), 3 focal hyperintensities of the brain that turned out to be the first evidence of multiple sclerosis in 2 patients and sarcoidosis in 1 patient, and 1 temporal metastasis. Other pathologic conditions, such as parotid gland or petrous bone apex tumors, were unrelated to the audiovestibular symptoms.

CONCLUSIONS

This study indicates that contrast-enhanced MRI can be used to assess a significant number of different pathologic conditions in patients with audiovestibular disorders.

A novel microperfusion system for the long-term local supply of drugs to the inner ear: implantation and function in the rat model

Local therapy is practiced for middle and inner ear diseases but is usually restricted to cases of ear drum perforation or repeated invasive intratympanic drug application. Perfusion of drugs on the round window or through the scalae of animals using a pump system suggests that the chronic local drug treatment might also be feasible in humans. However, drug delivery systems that are currently on the market involve repeated reimplantation if they are to be used for long-term drug supply. A bone-anchored, totally implantable micro-drug delivery system (MDS) for patient-controlled drug supply has been developed [Lehner et al., 1997]. In this study, we show the first successful long-term in vivo test of the MDS micro-pump in rats. The process of implantation and first functional tests will be described. The biomaterial used to manufacture the delivery system did not cause any inflammation reaction in any of the 9 animals successfully implanted. After activation of the micro-pump, the drug reservoir and port was found to be fluid-tight. Bolus applications of tetrodotoxin (TTX) to the round window induced a transient decrease of evoked brainstem responses. In 2 animals which carried the MDS for more than 8 months the proper functioning of the pumping device was examined in a 2-3 week interval over a 3 month period. The MDS can be autoclaved even after long-term implantation and can then be reused for subsequent implantations. Designed for life-long implantation in humans, the demonstration of an effective long-term drug supply to the inner ear using the MDS provides an encouraging first step towards future long-term drug treatment of the inner ear in humans.

Sternberg's canal--cause of congenital sphenoidal meningocele

We present a case of a 29-year-old female complaining of right-sided watery nasal discharge. Radiological investigations identified an intrasphenoidal meningocele. The origin of the meningocele was pinpointed to the right parasellar region and was confirmed surgically. The parasellar bony defect appeared to be due to persistence of the lateral craniopharyngeal canal (Sternberg's canal). Therefore, we assume a congenital origin for the intrasphenoidal meningocele found in the patient. Acquired bony defects of the sphenoid sinus are unlikely at the fusion planes of the different sphenoid bone components. Knowledge of the complex ontogeny of the sphenoid bone is an important key to differentiating between congenital and acquired sphenoid sinus meningoceles.

The role of endonasal surgery in the management of frontoethmoidal osteomas

Recently endonasal surgery has been considered to be a valuable contribution in the management of paranasal sinus osteoma. A retrospective evaluation study of 34 frontoethmoidal osteomas (23 frontal and 11 ethmoidal osteomas) treated at a tertiary care facility from 1990 to 1999 is presented. Twenty three osteomas (68%) were resected endonasally. Eleven osteomas (32%) were removed using an osteoplastic frontal sinus approach with coronal incision. In 5 cases of huge osteomas originating at the anterior frontal sinus wall, reconstruction of the resected anterior-frontal sinus wall was achieved by autologous outer table grafts harvested from the parietal region. Endoscopic and radiological follow-up ranging from 1 to 32 months showed three incomplete endonasal osteoma resections. Complete osteoma removal was achieved via endonasal revision surgery in two of these cases, while the third small residual osteoma remains under observation. There was no case of osteoplastic osteoma removal where incomplete osteoma resection became obvious during follow-up. Ethmoidal osteomas without extrasinusal extension can be resected endonasally. The endonasal approach should be considered also for frontal sinus osteomas if (1) sufficient frontal sinus access can be achieved endonasally, (2) the osteoma is placed medially to a virtual sagittal plane through the lamina papyracea, and (3) the tumour base is at the inferior part of the posterior frontal sinus wall. We favour the osteoplastic frontal sinus approach with coronal incision if an external approach is required to achieve tumour resection with the best aesthetic results.

Sigmoid and transverse sinus thrombosis after closed head injury presenting with unilateral hearing loss

Sinus thrombosis has rarely been associated with closed head injury; more often, thrombosis of the sigmoid or transverse sinus is caused by otogenic inflammations or tumours, or occurs during pregnancy. Symptoms are frequently vague, while untreated thrombus progression may be fatal due to venous congestion and infarction. We report a 32-year-old man presenting with right hearing loss, tinnitus and headache 2 days after a closed head injury. Neurological examination showed no additional abnormality. The EEG showed focal bifrontal slowing. CT revealed a fracture of the occipital bone. MRI and MRA demonstrated complete thrombosis of the right sigmoid and transverse sinuses. After 2 weeks of intravenous heparin therapy followed by warfarin, the patient's hearing improved and MRI and MRA showed complete recanalisation of the sigmoid and transverse sinuses. Venous sinus thrombosis can be an undetected sequel to head injury. Appropriate imaging studies should be carried out to enable therapy to be started as soon as possible.