[Ultrasonographic and computed tomographic findings in a goat with mediastinal lymphocytic thymoma]

This case report describes the clinical, sonographic, computed tomographic and pathological findings in a 9-year-old goat with mediastinal lymphocytic thymoma. The goat was referred to the Department of Farm Animals because of weight loss and dyspnoea. The lead clinical findings were increased heart rate, increased respiratory rate and heart sounds heard only on the right side. Ultrasonographic examination revealed a massive amount of fluid and an echogenic corrugated mass ventral to the lungs in the thoracic cavity on the left side. Computed tomography showed that the mass was very large and diffusely mineralised. A tentative diagnosis of mediastinal neoplasia was made, and the goat was euthanized. Postmortem examination revealed a cauliflower-like, pedunculated tumour, which occupied the entire left thoracic cavity and displaced the left lung. Based on histological evaluation, the tumour was diagnosed as a lymphocytic thymoma.

[Short and long term results of endolymphatic sac surgery: a patient-questionnaire based study]

INTRODUCTION

The endolymphatic sac surgery for the treatment of Meniere's disease has been described since the 1920s. The success rate of this technique in terms of vertigo control has been reported to be 50-80%. However, the value of this treatment method remained controversial. Furthermore, the reliable identification of the endolymphatic sac intraoperatively can be challenging in some cases. This study examines the short-, middle- and long-term results in a larger cohort of patients.

MATERIALS AND METHODS

In 74 patients, vertigo control, tinnitus and degree of satisfaction was evaluated by means of a questionnaire retrospectively. Additionally, the diagnostic value of the electrocochleography (EcochG) was determined.

RESULTS

The overall vertigo control rate was more than 70% in patients followed up for two years and has reached 81% in patients followed up for more than two years. Hearing preservation rate was 61%. Tinnitus has disappeared in 11% and improved in 23% of the patients. In 47% of the patients it was unchanged and in 19% worsened. The difference in EcochG results pre- versus postoperative was highly significant.

CONCLUSIONS

ELSS is a useful tool in the management of Ménière's disease, in particular in patients that do not benefit sufficiently from conservative therapy.

[Middle ear surgery in Mongolia--first results with middle ear prostheses]

BACKGROUND

Medical care of the Mongolian population is still far behind the standard of industrialised countries. Also in the field of otorhinolaryngology there are clear deficits in regard to an adequate diagnosis and treatment of difficult cases. Microsurgery of the ear is still in the very beginning due to missing essential equipment and surgical skills of the few ORL-units that exists in the country. The integration of tympanoplastic procedures into surgical routine is the main goal of a support programme that exists between the medical faculties of the universities of Wuerzburg (Germany) and Ulan Bator (Mongolia). The aim of this work is to present the outcome of these operations in Mongolia.

METHODS AND PATIENTS

As a result of the continuous education and support programme it was possible to perform 90 tympanoplastic procedures between 2005 and 2006 in the local ORL center of Ulan Bator (EMJJ-clinic). The focus of this report is on the postoperative audiological outcome following reconstruction of the ossicular chain either using autologous ossicles or middle ear prostheses. Besides, prostheses made of polyethylene or Teflon (Russian production) as well as titanium prostheses (Kurz Company, Germany) were implanted.

RESULTS

The final evaluation of the audiological results was performed 6 month postoperatively. The titanium prostheses provided the most favourable hearing improvement (mean 26 dB) when compared to the other materials (polyethylene 7 dB, Teflon 18 dB), but also compared to the autologous ossicles (8,6 dB).

CONCLUSIONS

The standard tympanoplastic procedures, which were developed over decades, proved to be highly reliable also in a country with reduced medical care. The hearing results obtained especially with titanium prostheses demonstrated, that this highly biocompatible alloplastic material is the most suitable and reliable for middle ear reconstruction also in a difficult surrounding.

[Exostoses of the external auditory canal. Is the cold water hypothesis valid for patients in continental areas?]

INTRODUCTION

Exostoses of the external auditory meatus are benign masses of tympanal bone that can lead to infections of the external auditory meatus in advanced cases and then need surgical treatment. Regular irritation of the auditory meatus by exposure to cold water was implicated in the causation of exostoses long ago. The present study investigates the cold water hypothesis in a patient group of continental origin. The surgical procedures and results are discussed.

STUDY DESIGN

Retrospective study.

MATERIALS AND METHODS

We present the epidemiological and aetiological data and postoperative findings recorded for 144 patients (167 procedures) who underwent surgical removal of exostoses from the external auditory meatus in the hospital in Würzburg within 11 years. In attempt to glean further information about the aetiology, patients were also asked to complete a questionnaire on participation in water sports and their symptoms before and since the operation.

RESULTS

Most of the patients (94%) had taken part in water sports for some years, more than 80% of them several times weekly. The most common indication for surgical removal was recurrent infection of the external ear. Although 50% of the patients reported improved hearing, no higher sound threshold was observed. Reversible complications (ear drum performation, tinnitus, opening of mastoid cells) were observed in 18% of the patients. One patient had a stenosis of the auditory canal caused by scar tissue.

CONCLUSIONS

Surgical removal of exostoses in the external auditory canal is frequently fraught with controllable complications. The indications for their surgical removal should be strictly applied; the presence of exostoses in isolation is not an acceptable indication for surgery. Removal of exostoses is an adequate way of avoiding recurrent external ear infections. Improved hearing can be expected only if the self-cleaning function of the external auditory meatus is improved.

[Results in otosurgically treated patients with acoustic neuroma. Part 1: Facial nerve function after translabyrinthine and middle fossa resection]

BACKGROUND

Regardless of all efforts to preserve a residual hearing, facial nerve function is still the primary issue for patients with acoustic neuromas. Since alternative methods like the gamma-knife treatment are of increasing importance, results after surgery have to be compared and discussed critically.

PATIENTS

The results of 538 patients operated at the Dept. of Otolaryngology, Head and Neck Surgery, University of Wuerzburg between 1989 and 2004 are presented. 392 had surgery via a middle fossa, 146 via a translabyrinthine approach.

RESULTS

Shortly after surgery 82.2 % of patients showed no facial palsy. 74 patients had an incomplete, 7 a complete paresis. After 12 months 144 of the patients operated on via middle fossa approach showed no palsy, 13 had an incomplete and one a complete paresis. Out of 76 patients operated on translabyrinthine approach 75 had no paresis, one had an incomplete, and no patient had a complete paresis. There was no difference between intrameatal tumors and tumors extending beyond the porus. Regular facial nerve function was seen in 93 %, postoperatively. Permanent paresis was seen in 0.4 % of cases.

CONCLUSION

Acoustic neuroma confined to the internal meatus or with minor extension into the cerebello-pontine angle (i. e. no contact to structures of the brain stem or vessels of the posterior fossa) are feasible for resection via a middle fossa or translabyrinthine approach. The possibility of hearing preservation combined with low morbidity and good results of facial nerve function makes these approaches the treatment of choice for this group of tumors.

Therapy of auricular keloids: review of different treatment modalities and proposal for a therapeutic algorithm

Keloids are abnormal wound reactions of connective tissue. Auricular keloids can develop as a result of, e.g., otoplasty, ear piercing, or skin trauma. A wide variety of therapeutic options exists, including surgery as primary treatment. Furthermore, there are medical, physical, radiotherapeutic and experimental options. The present paper focuses on the different techniques including the therapeutic outcome and quality rating for each chosen pathway. In addition to the experience of the university hospitals, a thorough review of the literature was performed in order to update and compare today's therapeutic options. Surgical techniques are customized to the lesion's specific localization and extent. They may include revision of otoplasty. With medical treatment, established modalities such as steroid injection have to be distinguished from experimental methods like interferon, 5-FU, verapamil, imiquimod, or mitomycin C. Radiation is generally accepted to be effective, especially applied accompanying surgery, but needs to be restricted due to possible side effects. Physical therapy, e.g., pressure in a variety of application modalities, has gained a profound position in the therapy of auricular keloids. The success rates of the different treatment modalities vary markedly, and the number of patients per study is considerably low. Resuming the results, a periodic follow-up and good patients' compliance are mandatory to early realize and treat auricular keloids. However, studies are needed to evaluate accepted and experimental therapies including larger number of patients.

Skin conductance or entropy for detection of non-noxious stimulation during different clinical levels of sedation

BACKGROUND

State entropy (SE) measures electroencephalographic signals, whereas response entropy (RE) also includes frontal electromyographic activity. In the presence of electromyographic activity, the RE index is larger than the SE index, the difference being denoted as RE-Delta (RE-Delta= RE - SE). Skin conductance (SC) may be expressed by a slow reacting variable, the mean SC level, the derivate of the mean SC level (D-SC), the number of SC fluctuations (NSCF) or the amplitude of the SC fluctuations (ASCF), which directly shows skin sympathetic nerve activity. The goal of this study was to evaluate whether these SC and entropy variables could differentiate between the responses obtained to load sound stimuli at different sedation levels before the induction of general anaesthesia.

METHODS

Twenty women scheduled for gynaecological laparotomy were studied. The modified observer's assessment of alertness sedation (OAAS) was used to classify the patients' hypnotic levels. White sounds (98 dB) were given at OAAS level 5 without propofol, at OAAS levels 4-3 and 3-2 with propofol and at OAAS levels 3-2 and < 2 with propofol and remifentanil.

RESULTS

RE and SE showed a steady decline from OAAS level 5 to level < 2 (P < 0.01). RE-Delta did not discriminate between any of the OAAS levels (P= NS). The mean SC level discriminated between OAAS levels 4-3 to < 2 (P < 0.01). D-SC discriminated between all the different OAAS levels (P < 0.01). NSCF discriminated between OAAS levels 5 to 3-2 (P < 0.05), but did not discriminate at OAAS level 3-2 between propofol alone or combined with remifentanil, or between OAAS level 3-2 and < 2. ASCF differentiated between OAAS levels 5 and 4 (P < 0.001) and OAAS levels 3-2 and < 2 (P < 0.05) only.

CONCLUSION

RE, SE and D-SC showed a similar discrimination between sound responses at the different sedation levels.

Comparison of skin conductance with entropy during intubation, tetanic stimulation and emergence from general anaesthesia

BACKGROUND

The number of skin conductance fluctuations (NSCF) expresses sympathetic skin nerve activity. The response entropy (RE) measures electromyographic and electroencephalographic activity in the forehead. The state entropy (SE) measures mainly electroencephalographic activity. When the suppression of frontal muscular activity is complete, RE is equal to SE. RE-Delta is defined as SE minus RE. The purposes of this study were to examine whether NSCF and RE-Delta correlate with signs of clinical stress during intubation and tetanic noxious stimulation and to elucidate how rapidly and accurately entropy and NSCF react during emergence from general anaesthesia.

METHODS

Twenty women scheduled for gynaecological laparotomy were studied. During intubation in remifentanil and propofol general anaesthesia, NSCF and RE-Delta were correlated with the clinical stress score. After a wash-out period, two series of tetanic stimuli were given, the first with (R+) and the second without (R-) remifentanil infusion. The tetanic pre-stimuli periods were compared with the tetanic post-stimuli periods, and R+ was compared with R-. During emergence, the responses of entropy and skin conductance were related to the time of extubation.

RESULTS

NSCF correlated well with the clinical stress score during intubation (r(2)= 0.73, P < 0.0005). RE-Delta showed a weaker correlation (r(2)= 0.33, P= 0.007). During tetanic stimuli, the NSCF pre-stimuli level was lower than the post-stimuli level (P < 0.001), and the NSCF R+ response was lower than the NSCF R- response (P= 0.002). RE-Delta did not show similar differences. During emergence, RE reacted before NSCF and SE (P= 0.003).

CONCLUSION

NSCF was better than RE-Delta for the measurement of clinical stress during intubation, and was sensitive to tetanic stimuli at different opioid analgesic levels, by contrast with RE-Delta. Both modalities were able to predict emergence at the end of anaesthesia, but RE was more rapid.

[The integrated PET/CT: technological advance in diagnostics of head and neck recurrencies and CUP?]

BACKGROUND

In the last years (18)F-Fluoro-deoxy-glucose (FDG)-positron emission tomography (PET) worked satisfactorily as auxiliary method in order to show recurrency of head and neck tumors and to detect primary tumors in case of CUP especially when CT and MR imaging failed to identify the tumor accurately. The correlation of FDG hypermetabolism and anatomical structures is now provided by a new technology which is integrating PET and CT: Integrated PET/CT represents a new technical development, which combines the advantages of CT and PET.

PATIENTS

In a retrospective investigation 84 non selected PET/CT studies of 83 patients with recurrent head and neck disease and CUP were critically analyzed.

RESULTS

33 cases had positive PET findings. 5 of these 33 cases showed false-positive findings. In 51 PET studies there was not found any sign of suspicious FDG hypermetabolism.

CONCLUSION

Integrated PET/CT delivers substantial progress in detecting tumor localization. False positive findings have to be considered and therefore indications should be strictly limited to special cases of head and neck tumor recurrency, cases with complex anatomical sites and CUP.

[Significance of PET and integrated PET/CT in the diagnostics of occult primary tumors]

BACKGROUND

In the last years (18)F-FDG-positron-emission-tomography (PET) worked satisfactorily as helpful auxiliary method in order to verify recurrency of head and neck tumors and to detect primary tumors in case of CUP syndrome especially when CT and MR imaging failed to identify the tumor accurately. Fusion of FDG hypermetabolism in PET scan and anatomical structures is achieved by integrating positron emission tomography with CT and provides improvement also in case of CUP syndrome. This retrospective study shows 47 patients with neck metastases where PET or PET/CT helped to detect primary tumor site.

PATIENTS

In a retrospective investigation 49 PET studies of 47 patients with CUP syndrome were analyzed.

RESULTS

9 cases had positive PET findings, 1 case false-positive. 5 cases were false-negative. In 40 PET studies there couldn't be found any sign of suspicious FDG hypermetabolism.

CONCLUSION

PET and PET/CT deliver a certain improvement in localization of primary tumor site and therapeutical strategy.

Difficulties in the fixation of prostheses for voice rehabilitation after laryngectomy

In most patients with advanced or recurrent laryngeal or hypopharyngeal cancer, total laryngectomy is indicated. This means the loss of three main functions: phonation; respiration; and the prevention of aspiration during deglutition. Laryngectomy patients have various options to restore phonation: an oesophageal voice; an electrolaryngeal voice; or a tracheo-oesophageal voice. In the last case a silicone rubber shunt valve is placed in the tracheo-oesophageal wall and phonation is generated when exhaled air is forced through the oesophagus and neopharynx. This method is widely applied in Western Europe. In this paper we review the literature on fixation problems with shunt valves, tracheostoma valves and heat and moisture exchange (HME) filters. Tracheo-oesophageal speech without a valve is not considered. Despite 22 years of experience with the implantation of tracheo-esophageal shunt valves and many improvements in the design, problems still remain, such as biofilm formation with subsequent leakage through the valve, the need for frequent and inconvenient replacements, fistula enlargement leading to leakage around the device and reduced fixation, and infections. The high cost of shunt valves is a drawback to their use worldwide. To enable hands-free speech, different types of tracheostoma valve have been developed. These valves are fixed to the skin or to the tracheostoma by means of an intra-tracheal device. An HME filter is used to protect the airway and maintain physiological balance. Such devices are only suitable for a selected group of patients as fixation to the skin or trachea can be a major problem. Speaking and coughing cause pressure increases, which often result in mucous leakage and disconnection of the valve and/or HME filter. Recommendations are made for future improvements in fixation techniques.

[Surgical voice restoration following total laryngectomy]

In spite of the progress made in organ-preserving therapy modalities, including endoscopic or external partial laryngectomies, radiotherapy or chemoradiation in many patients with advanced laryngeal and hypopharyngeal carcinomas, total laryngectomy remains the only safe possibility for long lasting local tumour control. The existing strategies for a sufficient restoration of voice following total laryngectomy are still controversial. Besides the strictly conservative methods of esophageal voice and electronic devices, different surgical procedures are carried out worldwide. At present, the exclusively surgical voice shunt techniques are only offered in a few very specialized centres. In Germany, three surgical methods are in use: (1) microvascular laryngoplasty according to Hagen (> 300 cases), (2) the "jejunal speaking siphon" according to Ehrenberger modified by Remmert (> 60 cases), and (3) the modified Asai-technique according to Maier and Weidauer (> 80 cases).