[Jugulotympanic paraganglioma: therapy concepts under development]

BACKGROUND

The operative treatment and radiation therapy of jugulotympanic paragangliomas (JTP) are still a matter of controversial discussion. In spite of various improvements during the last 50 years, selecting the appropriate treatment modality (surgery, radiation, or observation) is still a challenge.

PATIENTS

During a 16-year period, 44 patients with 45 JTP (10 at level A/B and 35 at level C/D according to Fisch) were seen at the ENT-department in Fulda. Forty-one cases were treated surgically.

RESULTS

Complete resection was possible for level A/B in 100% of the patients (n = 10). Residual tumor was demonstrated for level C in 23% of the patients (5/22) and for level D in 40% (4/10) with a median follow-up time of 69 months. In two cases residual tumor was treated by radiation. Six patients with residual paraganglioma tissue were maintained under observation without any evidence of tumor progression (median follow-up time 39 months). We report one death after the attempt to resect a large residual paraganglioma that had already caused brain stem compression. A sufficient duraplasty could not be achieved following radiation therapy.

CONCLUSIONS

Complete tumor resection of jugulotympanic paragangliomas of levels A and B is often possible without injury to the cranial nerves. Extensive tumors present difficulties in complete tumor resection and increase the risk of cranial nerve injuries. Advanced paragangliomas therefore require an individualized therapeutic regime including surgery, radiation therapy, and observation of tumor growth.

[Reconstruction of the forehead region with tabula externa of the skull]

BACKGROUND

Calvarial bone graft is often used in reconstructive cranio-facial surgery. As most common three different forms can be distinguished: outer-table bone, full thickness grafts and composite flaps (bone with a periostal or muscular pedicle).

PATIENT AND METHOD

An extensive fibrous dysplasia of the frontal region was removed in a 26 years old patient. Reconstruction was carried out with alloplastic material achieving a good esthetic result. Recurrent seroma and occurrence of a fistula demanded removal of the alloplastic material and en-bloc reconstruction of the forehead region was accomplished with a parietal outer-table graft. Within a follow-up time of one year a good esthetic and stable reconstruction has been achieved.

CONCLUSION

Split-thickness calvarial bone is still a versatile graft in reconstruction of the forehead region. Although a low rate of side effects in harvesting calvarial bone grafts are in general expected, one has to be aware of dural lesions occuring in the donor site during craniotomy.

[Complications with permanent damage in endonasal paranasal sinus operations--more frequent in experienced surgeons?]

BACKGROUND

The rate of serious complications in endonasal sinus surgery has not gone down although optical aids are widely used nowadays. Are serious complications caused more often by unexperienced or experienced surgeons using a microscope and/or endoscope?

METHODS

We defined serious complications as follows: death, persistent neurological deficits or permanent loss of vision, and injury to the internal carotid artery. Two different studies were made: the first consecutive 300 interventions of 6 sinus surgeons were evaluated. Sixteen malpractice cases were analysed regarding the experience of the surgeon.

RESULTS

In 9 out of 16 malpractice cases serious complications were attributable to experienced surgeons, five to moderately experienced surgeons, and only two to an inexperienced surgeon (although he had extensive experience in external sinus surgery). There were 6 deaths, 6 neurologic defects, 2 visual disorders, and 2 injuries to the internal carotid artery without any sequelae. In 9 cases the serious complications were related to injury of the internal carotid artery, in five cases to perforation of the skull base. Twice the orbital wall was penetrated. In 1800 procedures performed by 6 surgeons, no serious complications were encountered. There were only lesions of the periorbit (n = 33) or CSF leaks (n = 8) without any permanent damage to the patient.

CONCLUSIONS

Even an experienced surgeon must always keep in mind that serious complications can occur in sinus surgery. One must constantly be alert to the possibility of anatomical variants or specific pathologic findings.

[Is chronic laryngitis associated with Helicobacter pylori? Results of a prospective study]

H. pylori is found in the stomach of patients with chronic gastritis. The infection is usually transmitted by the gastro-oral route and bacteria could be identified in saliva and dental plaque. An essential cause of chronic laryngitis is gastroesophageal reflux. The aim of the study was to evaluate if a H.pylori-associated chronic laryngitis exists. 38 patients with chronic laryngitis underwent gastroscopy. Biopsies were taken from the gastric antrum and body, lower, middle and upper esophagus. H. pylori was diagnosed by rapid urease test and histology. 14 of the patients (36.8%) were H.pylori-positive, but the bacteria could not be identified between stomach and larynx. 24 patients were H. pylori-negative. Seven patients (18.4%) suffered from esophagitis, six of these patients were H. pylori-negative. The H. pylori-infected patients received triple therapy for one week, in case of esophogitis Omeprazole 20 mg BID was prescribed. Six weeks later a follow-up endoscopy was performed. The eradication rate was 12/14 (85.7%), in all patients with reflux the esophagitis was cured. The laryngitis was clinically and endoscopically unchanged in ten of the twelve (83.3%) patients after successful treatment for H. pylori; in the remaining two patients as well as in the two H. pylori-positive patients the laryngitis was improved. In six out of the seven patients with esophagitis the laryngitis had healed completely and was improved in the remaining patient. It may be concluded that there is no evidence for the existence of H. pylori-associated laryngitis, suggesting that acid reflux is the underlying etiology.

[Experiences with hemangiopericytoma in cranial base surgery]

BACKGROUND

Haemangiopericytomas are rare vascular neoplasms which show either slow local tumour growth or aggressive progression in size with a high tendency of recurrence and metastasis. Manifestations of haemangiopericytomas in the area of the nose and sinuses are supposed to have a relatively benign course. To date clinical and histological parameters for prognosis are uncertain. Therefore in a quite large number of cases only the clinical course allows to evaluate the dignity of a haemangiopericytoma.

PATIENTS AND RESULTS

We present our experience with five haemanglopericytomas in contact with the skull base out of a total number of 457 skull base tumours. The site of origin of these five haemangiopericytomas were: nasal septum, pterygopalatine fossa, oronasopharynx, temporal bone, and parotid gland. All neoplasms showed primary or recurrent tumor in contact with the skull base and an intracranial extension was observed twice. One patient died postoperatively of a cerebral infarction. Three patients showed one or more recurrences which were treated surgically. In one case 5 recurrences occurred. Despite of 4 surgical procedures within a period of 15 months, the tumour could be controlled only for a short period of time, and the patient died 16 months after the first operation.

CONCLUSION

One has to consider that haemangiopericytomas of the head and neck show a potential malignant course. The vascular tumor may recur decades later. Adequate therapy and life-long follow-up are therefore mandatory in haemangiopericytomas. Complete surgical resection of the tumour is usually the treatment of choice, in spite of the high degree of surgical skill required, especially in advanced tumour and in case of recurrence.

[Tolerance, subjective complaints and mucociliary clearance in rhinitis sicca before and after nasal irrigation with Rhinomer Force 1]

BACKGROUND

Rhinitis sicca is a widespread disease, caused by a variety of factors. There are many different treatments, but none is more reliable than the other.

METHODS

In a prospective study we examined 12 patients before and after a ten-day course of nasal irrigation with Rhinomer Force 1 regarding their symptoms, the mucociliary clearance measured with the saccharin test according to Andersen and tolerance of therapy.

RESULTS

Improvement of nose breathing (57%), sensation of mucous running in the pharynx (42%), feeling of a dry nose (42%, significant p = 0.0313). The overall improvement was significant (67%, p = 0.054). Mucociliary transport analysed for each side of the nose (24 sides) resulted in 38% improvement (up 10 min in average), 12% same result, 50% worsening (down 12 min in average). The acceptance was reported as very good in 91% of the study group.

CONCLUSIONS

Depending on the symptoms, a high to significant amount of improvement is documented after therapy with isotonic salt water solution. In our study the measurement of the mucociliary transport does not correlate with subjective symptoms. It does not appear to be an adequate tool for diagnosing rhinitis sicca or evaluating the success of treatment.

[Experiences in diagnosis of occult traumatic dural lesions of the anterior cranial base]

BACKGROUND

Meningitis or cerebrospinal fluid rhinorrhea can occur years or even decades after trauma and can be the first indication of a previously unidentified dural lesion. In spite of being difficult, precise localization of an occult traumatic dural lesion is a necessary prerequisite for duraplasty.

PATIENTS AND METHODS

In a retrospective study covering a period of 17 years, we identified 27 patients with occult traumatic dural lesions. The dural lesions were localized by high-resolution CT, MRI, fluorescein nasal endoscopy, and CT cisternography. In all cases the expected dural lesion was demonstrated and treated surgically.

RESULTS

In 23 out of 27 patients (85%), the rhinobasal fistula was detected as a bony defect by CT. Furthermore MRI examination in 100% (5/5), a preoperative fluorescein nasal endoscopy in 50% (10/20) and CT cisternography in 56% (5/9) were able to localize the dural lesion.

CONCLUSION

We recommend high-resolution CT and MRI as diagnostic tools of choice in searching for occult dural lesions. Fluorescein nasal endoscopy and CT cisternography are justified as invasive techniques if CT and MRI are inconclusive but clinically CSF leakage is still suggested. The patient will remain at risk of potentially fatal meningitis until the lesion is appropriately repaired by duraplasty. Therefore modern clinical and radiological diagnostic methods should be used to search for an unknown dural lesion.

Extranasopharyngeal angiofibroma in a 15-month-old child

Angiofibromas are usually characterized by typical location with involvement of the posterior nasal cavity and nasopharynx. They are most commonly found in adolescent males. Despite these facts, a case of an angiofibroma presented in a 15-month-old boy at an atypical site anterior and medial to the lacrimal sac. The tumor was resected via an endonasal, micro-endoscopic approach avoiding an external incision.

Extranasopharyngeal angiofibroma in a 15-month-old child

Angiofibromas are usually characterized by typical location with involvement of the posterior nasal cavity and nasopharynx. They are most commonly found in adolescent males. Despite these facts, a case of an angiofibroma presented in a 15-month-old boy at an atypical site anterior and medial to the lacrimal sac. The tumor was resected via an endonasal, micro-endoscopic approach avoiding an external incision.

[Early childhood angiofibroma in an unusual site]

Angiofibromas are usually characterized by their occurrences in adolescent males with a typical localization and involvement of the posterior nasal cavity and nasopharynx. Even the suspicion of an extranasopharyngeal angiofibroma or an angiofibroma in young children must be viewed in general with skepticism, although reports of angiofibromas with atypical localizations and manifestations in young children have appeared in the literature. Three cases of this fibro-vascular neoplasm with manifestations in the first decade of life and atypical localizations are presented: (1) an angiofibroma medial to the left lacrimal sac in a 15-month old boy, (2) a right paranasal localization in a 9-year-old boy and (3) an angiofibroma limited to the right sphenoid sinus in a 6-year old boy. In all three cases the neoplasm was resected via an endonasal, micro-endoscopic approach that avoided an external incision. According to the literature and based on our own experiences with typical histological findings in all three cases, the clinician has to be aware that the rare angiofibroma can occur in preadolescent children with atypical localizations. The endonasal surgical approach is without any doubt the least traumatic one and in selected cases allows resection of a circumscribed tumor considering functional and aesthetic aspects.

[Endonasal frontal sinus surgery with permanent implantation of a place holder]

BACKGROUND

Endonasal frontal sinus surgery is well established. It is not yet clear what degree of enlargement of the frontal sinus neoostium is required to achieve permanent drainage or whether stenting improves the results.

PATIENTS AND METHODS

Prospective survey with two groups: Group 1. included 10 patients (15 operations) who underwent endonasal sinus surgery because of chronic polypoid sinusitis with stenting of the frontal sinus neoostium for 6 months. Group 2. included 11 patients (21 operations) without stenting.

INTERVENTION

Endonasal frontal sinus surgery with extended drainage Draf Type II (NFA II according to May) with (group 1) and without (group 2) long-term stenting of the neoostium for 5 months using a silicone stent.

MAIN OUTCOME MEASURE

12-16 months postoperatively: flexible endoscopy of nose and frontal sinus; computed tomography; magnetic resonance tomography; Wilcoxon-Mann Withney-Test.

RESULTS

With stenting: neoostium endoscopically patent in 80% (including 20% with edematous swelling only at the opening to the frontal sinus), occluded by scar tissue in 6.7%, occluded by polyps in 13.3%. Endoscopy and CT/MRT together: normal mucosa and aeration in 93.3%, complete opacification in 6.7%. Without stenting: neoostium endoscopically patent in 33%, occluded by scar tissue in 48%, occluded by polyps in 19%. Endoscopy and CT together: normal mucosa and aeration in 71.4%, aeration and mucosal swelling in 14.3%, complete opacification in 14.3%. With stenting of the frontal sinus neoostium for six months endoscopic evaluation of the frontal sinus was possible in a significantly higher proportion of cases (p = 0.0416).

CONCLUSION

Long-term stenting of the frontal sinus significantly reduces the rate of recurrent stenosis of the frontal neoostium and is recommended in all cases where an extended frontal sinus drainage is necessary. The optimal design for such a stent has not yet been clearly defined.

[Osteoplastic surgery of the frontal sinus: indications, procedures and results apropos of 75 cases]

In a retrospective study we have evaluated 75 osteoplastic frontal sinus operations performed in Fulda (Germany) between 1979 and 1993. Fractures, infections, tumors and pneumatosinus represent the indications for surgery. The frontal sinuses were obliterated in 31 cases. The average duration of follow up was 3.8 years. The overall results were very good and without serious complications. Only one revision was necessary.

[Anatomic terminology and nomenclature for paranasal sinus surgery]

A consensus on the preferred modern usage of potentially confusing or ambiguous terms in sinus anatomy and nomenclature is described. These terms are intended to provide clear communication among otorhinolaryngologists worldwide and serve as a basis for discussion among anatomists. Terminology is based on Latin nomenclature. An attempt has been made to reconcile or eliminate duplication, redundancy, and overlap in terminology that have arisen over the past century. A key concept is that the ethmoid complex is divided into anterior and posterior sections by the basal lamella of the middle turbinate.

Endonasal microendoscopic pansinusoperation in chronic sinusitis. II. Results and complications

PURPOSE

We evaluated the long-term results and complications of endonasal pansinusoperation in chronic polypoid sinusitis.

PATIENTS AND METHODS

In a retrospective study, 170 patients were followed-up for 20 months to 10 years after bilateral endonasal microendoscopic pansinus surgery or ethmoidectomy. The follow-up consisted of a standardized questionnaire and clinical examination with the flexible endoscope.

RESULTS

We found that 85.6% of the ethmoid cell systems, 69.4% of maxillary sinuses, and 37.5% of frontal sinuses could be visualized endoscopically. The ethmoid mucosa was normal in 56% and thickened in 19%. Recurrent polyps were found in 25%. The evaluation--as per the graduation of results defined by us as a combination of examination findings and subjective assessment of the operative result--resulted in an operative success of 92%. Two studies dealing with the frequency of complications showed injury to the dura in 2.3% to 2.55% and periorbital injury without permanent sequelae in 1.4% to 3.4%. Because of two cases of bleeding from the internal carotid artery, the problems of vascular complications in particular will be thoroughly discussed.

CONCLUSION

More than 90% of patients with chronic polypoid sinusitis gain long-term satisfying results after endonasal ethmoidectomy with microscope and endoscope. For minimizing the risk of injury of the optic nerve or the internal carotid artery preoperative, computed tomography is necessary. A special training program is recommended.

[Possible indications for temporalis muscle flaps in plastic-reconstructive surgery of the head and neck]

BACKGROUND

In reconstructive plastic surgery, the temporalis muscle has proven to be a reliable and versatile flap for a wide field of indications. The temporalis muscle is a flat, fanshaped muscle with a generous blood supply and innervation from the trigeminal nerve.

METHODS AND RESULTS

Based on our own experiences in a total of 25 cases (12 cases involving muscle transposition for mouth reanimation, six cases involving stabilisation of a duraplasty including protecting the internal carotid artery in one case, four cases involving reconstruction of the orbital floor or the base of the skull, and three cases involving recontouring the lateral face) and a review of the literature we give an up-to-date overview of the different indications for the temporalis muscle flap. These include: a) treatment of facial nerve paralysis, b) recontouring of the lateral face, c) reconstruction of skull base, orbita, and oropharynx, d) stabilization of duraplasty, e) protection of internal carotid artery, f) in temporomandibular joint surgery, and g) for obliteration in ear surgery.

CONCLUSION

Because of the wide range of indications, the temporalis muscle flap remains a versatile and important tool in plastic reconstructive surgery.

[Malignant degeneration of juvenile laryngeal papillomatosis?]

BACKGROUND

Spontaneous malignant transformation of laryngeal papillomatosis was in the past mostly negated, or the discussion in literature was rather toned down and reserved. Therefore, from a biological and prognostic point of view, HPV infection of the larynx seems to carry a different weight than a viral infection in genital region. According to general consensus, secondary, malignant transformation in juvenile papillomatosis occurs in irradiated patients and leads to the conclusion that radiation therapy of this disease is presently contraindicated. Because there is as yet no causal and curative treatment, repeated and frequent removal of papillomatous tissue by microlaryngoscopy may often be necessary to keep the airway patent.

PATIENT, METHOD AND RESULTS

We diagnosed and treated an advanced laryngeal squamous cell carcinoma with lymphatic metastasis in a 50-year old male. Juvenile papillomatosis had been diagnosed already at the age of five, and at the patient's last presentation 5 years ago (age 45), typical clinical and histological features of laryngeal papillomatosis had been observed. Furthermore, virus infection of the papillomatous tissue (HPV-6/11) was proved by using the technique of in-situ hybridisation. Risk factors for malignant transformation, such as smoking, alcohol or radiation, were denied by the patient.

CONCLUSIONS

From these aspects, a spontaneous, malignant transformation of laryngeal papillomatosis must be considered with regard to six similar observations in the German and English literature. In the reported case, a tumoural origin in the flat laryngeal mucosa in close neighbourhood to the former site of papillomas, is less probable, albeit not ruled out completely, since continuous changes from benign squamous papilloma to atypical, invasive tumour and a HPV-infection in the carcinomatous tissue could not be proved by in-situ hybridisation.

[Long-term follow-up of fronto-basal dura-plasty]

A safe closure of a dura lesion is necessary on account of the risk of potentially fatal (late) meningitis. 161 duraplasties of the frontal skull base carried out from 1979 to 1994 at the ENT-department Fulda were evaluated in a retrospective study in regard to etiology, operative techniques and results. Duraplasty of the rhinobasis was indicated in 70 cases of rhinobasal trauma, 47 cases after paranasal sinus surgery, 36 cases of tumors and 8 malformations. After an average follow-up time of 6 years the patients were interviewed for postoperative liquorrhea, sinusitis treated with antibiotics and meningitis. As an objective measure to verify the tight closure of the treated CSF-leaks a fluorescein test was performed in 50.9% 6 to 8 weeks after the operation. Duraplasty was successful in more than 96%. The approach and technique to perform a duraplasty have to be chosen individually considering size, location and etiology of the dural defect. In the majority of dural defects in the area of the frontal skull base reconstruction can be carried out now a days via an endonasal approach. By use of allogenic tissue, a mucosal flap from the surrounding area to cover the graft and fibrin clue good results were obtained.

Occult malformations of the skull base

Occult malformations of the skull base are rare anomalies. They are often not detected until they give rise to complications such as meningitis or cerebrospinal fluid rhinorrhea. We used high-resolution computed tomography, fluorescein endoscopy, cisternography, magnetic resonance imaging, and duraplasty to diagnose occult malformations of the skull base in 4 patients. The four patients had had between 4 and 6 attacks of meningitis. Cerebrospinal fluid rhinorrhea was confirmed in 3 cases. The following occult malformations were found: (1) an encephalocele of the glabella/cribriform plate and a meningocele at the petrous bone apex, (2) a meningoencephalocele at the petrous bone apex, (3) dural lesions in the regions foramen rotundum/sphenoid sinus and frontal sinus/cribriform plate, and (4) a dural lesion of the sphenoid sinus. In patients presenting with recurrent meningitis, meningitis with isolation of upper airway pathogens, or cerebrospinal fluid rhinorrhea, modern diagnostic methods should be used to search for dural lesions. Diagnosis of an occult malformation makes it possible to perform the necessary surgical repair and thus prevent the further occurrence of potentially fatal episodes of meningitis.

Effect of omeprazole on the course of associated esophagitis and laryngitis

Esophagitis has increasingly been implicated as a cause of chronic laryngitis and there is some evidence that gastro-esophageal reflux disease (GERD) is more common in patients with laryngitis. The aim of this study was to evaluate whether patients with esophagitis and laryngitis responded to treatment with omeprazole. Of 74 consecutive patients with endoscopically proven GERD, 21 had laryngitis. These 21 patients with associated esophagitis and chronic laryngitis were treated for 4 weeks with omeprazole 40 mg per day. After 2 weeks of treatment and at the conclusion of the study, 2 weeks later, esophagoscopy and laryngoscopy were performed and the patients responded to a questionnaire on their symptoms. The follow-up period was 1 year. Twenty-one of the 74 patients (28.4%) had esophagitis (grade I, n = 12; grade II, n = 9) and associated laryngitis (grade I, n = 14; grade II, n = 7). The severity of the esophagitis accorded with the severity of the laryngitis. After 2 weeks' treatment with omeprazole, both the esophageal and the laryngeal symptoms had improved in all 21 patients. Endoscopically, the healing rates were 62% for esophagitis and 33.3% for laryngitis. At the end of the study period, at 4 weeks, all patients were symptom-free and the esophagitis and laryngitis had healed completely. No patient suffered from drug-induced side effects. Patients with associated laryngitis and esophagitis should be given adequate anti-reflux therapy. Both the laryngeal and esophageal symptoms improved with the omeprazole treatment, suggesting that reflux was the underlying etiology.

Computer-assisted documentation and analysis of wound healing of the nasal and oesophageal mucosa

Our aim was to analyse the dynamics of healing processes in the nose and oesophagus by videoendoscopic examination and reconstruction of the natural dynamics and continuity of a process using modern computer technology and so-called morphing software. Thirteen patients were followed-up for six months after sinus surgery and three weeks after oesophagitis. Four overlapping and meshing phases of wound healing following sinus surgery with significant interindividual differences. Topical budesonide shortened the duration of wound healing phases. Healing of oesophagitis occurred approximately symmetrically from the wound edges to the centre with constant velocity. Computer-assisted morphing enables dynamic analysing of mucosal processes under the following preconditions: Availability of a valid imaging method for documentation and measurement with the generation of congruent images. The process under analysis must run without sudden leaps and there must be adequate choice of timing of single measurement procedures.

[Pneumosinus dilatans frontalis. Etiology, symptoms and surgical technique]

BACKGROUND

Pneumosinus dilatans of the frontal sinus is a very rare condition in which deformity is caused by progressive enlargement of the brow ridges and lower forehead.

PATIENTS

Etiology of the reported two cases was unknown although some hypotheses have been presented.

RESULTS AND CONCLUSIONS

We corrected the aesthetic deformity using an osteoplastic flap and removing horizontal bone chips from the anterior wall of the frontal sinus. Postaoperative results were satisfactory. In one case, obliteration of the sinus with fat was necessary, because of polypous mucosa.

[Long-term results of endonasal frontal sinus surgery]

Most conditions of the frontal sinus requiring surgery can now be managed successfully by endonasal procedures. To date there has been no clear position regarding indications and results of different types of endonasal frontal sinus drainage. In a retrospective study we evaluated long-term results of Draf's type II and III endonasal frontal sinus drainages using endoscopy and computed tomography. Twelve to 98 months following type II drainage, 58% of 83 frontal sinuses were ventilated and normal. A ventilated frontal sinus but with hyperplastic mucosa was seen in 12%. Scarred occlusion with total opacification on CT occurred in 14%. Furthermore, total opacification in 16% was due to recurrent polyposis. Patients were free of symptoms or had only minor problems in 79%. Twelve to 89 months following type III drainage, 59% of 81 frontal sinuses were ventilated and normal. A ventilated frontal sinus with hyperplastic mucosa was seen in 17%. Scarred occlusion with total opacification on CT was present in 7%. Furthermore, total opacification in 16% was due to recurrent polyposis. In all, 95% of the patients were free of symptoms or had only minor problems. Combining our results with those of other authors and utilizing the physiology of wound healing after sinus surgery, we developed a protocol of differential indications for endonasal frontal sinus drainage.