[Extramedullary plasmacytoma--manifestation in petrous bone]

BACKGROUND

Extramedullary plasmocytoma of the temporal bone is a rare neoplastic disorder. Only a very few cases are described in the world literature.

CASE

We report on a patient who presented with the clinical signs of a glomus jugular tumor. Postoperative histological evaluation revealed an extramedullary plasmocytoma of the temporal bone.

CONCLUSION

If a glomus tumor is suspected, histological investigation appears necessary if surgery is not possible or is contraindicated.

Cranial vault moulding by the transcutaneous activation of implanted magnets

The technique of distraction osteogenesis has not been widely used in the treatment of injuries of the head and face because of the need for external fixators. By using magnetic, rather than mechanical, forces to drive bone movement we hope to expand the applications of the technique to include the treatment of cranial vault deformities. Fifteen immature rabbits were studied. When they were 6 weeks old each had a magnet fixed to their left parietal bone. A head frame was attached and a magnet of either the opposite polarity to, (group 1), or the same polarity as, (group 2), the implanted magnet was mounted on the frame. Five weeks later the rabbits were sacrificed. There were significant differences in parietal skull width and in several measures of skull length between the animals in group 1 and those in group 2. These results demonstrate that, in this model, magnetic forces can be used to modify skull growth.

[Laryngeal cancer treatment concept in metastases]

The prognosis of laryngeal carcinoma worsens dramatically with the discovery of primary or secondary lymph node metastases. Thus consistent prophylaxis and therapy of metastases is indispensable. The standard therapy of manifest cervical lymph node metastases is surgery, if possible using the approach of conservative neck dissection. In cases of a lymph node stage N3, i.e. fixated metastases with a diameter greater than 6 cm, individually adapted therapy in necessary because of the extremely poor prognosis. Elective treatment of the N0 neck is surgical, too; however, the site of the primary tumour, possibly infiltrated compartments and, accordingly, invasion of deep lymphatic vessels have to be considered. Special care is necessary if the so-called primitive glottis is invaded (arytenoid region, aryepiglottidian fold, epiglottis). In the case of distant metastases a temporary remission can be obtained with chemotherapy in most cases, but this chemotherapy should not be forced, because there exists no real chance of cure. The trend is towards less aggressive, outpatient schedules of chemotherapy.

Fistula of stapes footplate caused by pulsatile cerebrospinal fluid in inner ear malformation

Congenital malformations of the inner ear are well described, though the combination with cerebrospinal fluid (CSF) leaks remains controversial. In this paper a case of a bilateral Mondini malformation with a CSF otorrhea on one side is reported. The malformed stapes contains a perforation in the middle of the footplate and associated thinning analogous to a pothole in a mountain stream. The histological findings support the hypothesis of pulsatile flow of CSF as origin of the perforation of the footplate.

[Magnesium seeding in therapy of pediatric hemangioma of the temporal region, lower eyelid and orbit]

BACKGROUND

Magnesium seeding of haemangiomas is a form of treatment already successfully used in 1900.

PATIENT

We report about a male infant with a haemangioma of the left temporal region, underlid and orbit. Maximum depth at the time of indication for magnesium seeding was 28 mm with an intraorbital extension of 7 mm. COURSE OF THERAPY: Magnesium seeding of the haemangioma first lead to a standstill and within 8 weeks to a significant remission. After this period, maximum depth was 6.7 mm without any intraorbital extension.

CONCLUSION

Magnesium seeding is a hopeful and low-risked alternative in the therapy of infantile haemangiomas.

Nasotracheal airway-oropharyngeal alimentary canal: a microvascular technique for reconstruction of the upper airway after total laryngectomy

Every patient who has to be laryngectomized because of a carcinoma is concerned with the loss of his or her voice and the presence of a permanent tracheostoma in his or her neck. While various methods for producing a substitute voice are available (esophageal voice, voice devices, voice-shunt operations with or without voice prosthesis), it is usually impossible after laryngectomy to reconstruct a complete upper airway so that the tracheostoma can be closed. One potential method for reconstruction of the airway is its division into a nasotracheal airway and an oropharyngeal alimentary canal. Ten Alsatian dogs were laryngectomized, and a microvascularly anastomosed jejunal autograft was inserted as a junction between the tracheal stump and the circularly exposed nasopharynx, while the pharynx was reconstructed separately. One week postoperatively, oral feeding could be started again; at the same time breathing was possible via the reconstructed nasotracheal airway, which was kept open by insertion of a silicone tube. By means of this microvascular technique, a complete nasal airway could be reconstructed surgically after laryngectomy.

Juvenile nasopharyngeal fibroma: androgen receptors and their significance for tumor growth

Since the publications of Martin, et al. (1948) and Schiff (1959), who were the first to report on the administration of sex hormones to juvenile nasopharyngeal fibroma (JNF) patients, several authors have described the different clinical effects and histologic changes after androgen and estrogen application. Since the mechanism of action of sex steroids in juvenile nasopharyngeal fibroma is almost unknown, the authors have studied androgen receptor binding in cultured tumor fibroblasts from three patients with JNF. Maximum androgen binding (Bmax) of the tumor fibroblasts approximated to that of genital skin fibroblasts, which served as a control androgen target tissue with high receptor density. Furthermore, in vitro experiments showed that the growth rate of tumor fibroblasts increased when testosterone was added to the culture medium, while the addition of two antiandrogens, cyproterone and flutamide, caused a reduction in growth rate. It is concluded from these results that JNF is a hormone-dependent tumor stimulated by testosterone whose growth rate may, at least in vitro, be reduced by antiandrogens such as cyproterone and flutamide.

[Fibrinolytic therapy in sudden deafness with recombinant tissue-type plasminogen activator. Hemorheologic and therapeutic effects]

In the course of a pilot study, the effects of fibrinolysis treatment with rt-PA (Actilyse, Thomae, Biberach; 100 mg) on the recovery of hearing and hemorheologic parameters were investigated in 12 patients suffering from sudden hearing loss. The authors' approach was based on two considerations, (1) the possibility that, in cases of sudden hearing loss, the oxygen supply to the cochlea is totally or partially blocked by a microthrombus which could be dissolved by rt-PA and (2) the fact that lysis markedly improves the flow characteristics of the blood (as has been demonstrated in studies with streptokinase and urokinase). This human-plasminogen activator, produced by genetic engineering, is superior (also in terms of possible side-effects) to other lysin enzyme preparations (streptokinase, urokinase) because of its highly selective effects on thrombi (low activation of plasma plasminogen) and its short half-life (approx. 4 min). In nine of 12 patients, the treatment brought about a marked improvement in hearing or its complete restitution (three of the patients has initially been deaf in the affected ear). In the three nonresponders there was serologic evidence of an inner-ear infection (neuroborreliosis, cytomegaly, influenza B). The most interesting rheologic effect was the reduction of plasma viscosity (average decrease about 18%), since such a reduction cannot be attained with other, comparable rheologic measures (isovolemic or hypervolemic hemodilution). In spite of the convincing hemorheologic effects, fibrinolysis cannot yet be recommended as treatment for sudden hearing loss. Further studies have still to be done on spontaneous healing, the effects of hemorheologic measures on the blood circulation of the inner ear, and on the oxygen requirements of the ear affected by hearing loss.

[Hormone dependence of juvenile nasopharyngeal fibroma]

Since Martin (1948) and Schiff (1959) first reported the use of sex hormones in JNF patients, many authors have described the various clinical effects and histological changes found after administration of androgens or estrogens. In 1980, Johns attempted unsuccessfully to detect estrogen receptors in the tissue of tumors from JNF patients. In 1987, however, Farag et al. succeeded in the demonstration of androgen receptors in homogenates of such tumor tissue.--In 1989, the authors were able to determine the uptake and receptor-binding of radioactively labelled dihydrotestosterone in cultured fibroblasts from a tumor from a 16-year-old JNF patient, and to confirm this result in two other cases. The maximum levels of hormone binding to the fibroblasts was much the same as is found with genital skin fibroblasts, included in the study as a control androgenic target-tissue with high receptor-density. At the same time it was demonstrated that it was possible to stimulate the tumor fibroblasts in vitro by adding testosterone to the culture medium. The attempt to block cell growth with the antiandrogen cyproterone acetate, was not successful, however. This can possibly be put down to the high progestogenic activity of this antiandrogen. Further in vitro studies with substances which are purely androgenic (e.g., flutamide) or with the acetate-free form of cyproterone (which has no progestogenic activity) will possibly be of help in the search for a substance capable of blocking tumor growth.

[Functional nasopharyngeal fiberoptic endoscopy for pre-therapeutic diagnosis of sleep apnea syndrome in infants. A case report]

We report a 2-year-old infant with severe obstructive sleep apnoea. The symptoms had deteriorated for several months, and indicated complete obstruction shortly after the child fell asleep, with reduction of the oxygen saturation to under 30%. Since the obstruction could only be interrupted by waking the child, a tracheostomy was proposed. Endoscopy under general anaesthesia revealed no pathological findings. The stenosis could only be seen using transnasal fibre-optic endoscopy when the obstruction occurred during sleep: the oropharyngeal wall collapsed at the level of the velopharyngeal sphincter. A tube passed through the nose and through the collapsing section of the pharynx to the entrance of the larynx prevented the apnoea. The parents were taught to introduce and fix the tube. After an observation period of 1 year the larynx had stabilized spontaneously, and the tube has to be introduced only rarely.

[Voice rehabilitation after total laryngectomy in West Germany. Current state of the art]

In 1987 Lopez published the results of a survey of voice rehabilitation after total laryngectomy as carried out by 400 North American ENT surgeons. In order to obtain the same information on the current state of voice rehabilitation in the German Federal Republic we did a similar survey of 103 ENT clinics. Ninety-five (92%) questionnaires were evaluated. Each year, 2200 laryngectomies are carried out in Germany. Oesophageal speech is the most frequently used form of voice rehabilitation in both countries. In the USA voice prostheses are fitted by 88% of the surgeons questioned to a total of 30% of patients; in Germany only 22% of the clinics in which laryngectomy is carried out fit these devices to a total of 5.6% of patients. External vibrators are used with equal frequency (28%). In contrast to the United States, where intraoral aids are currently used in 15% of patients, we do not employ these at the present time at all. Voice shunt operations (Staffieri, Asai, Amatsu etc.) are still carried out in 7 clinics (6.7%) on 0.7% of all patients (USA: 16% of surgeons on 15% of patients). In the United States 9% of patients are not rehabilitated compared with 6.7% in the Federal Republic.

[Diagnosis of oropharyngeal function with FLASH-MR tomography]

Magnetic resonance imaging (MRI) has several advantages over conventional X-ray methods: the patient is not exposed to radiation; images of any chosen level can be taken without changing the position of the patient; soft tissues are well differentiated; and artefacts due to dental materials are avoided. Thus, in certain fields of ENT diagnosis MRI is superior to computed tomography, for example, in the imaging of acoustic neuromas, glomus tumours and tumours of the parotids, oropharynx and orbit. The measuring time per slice image, which was previously measured in minutes, has been reduced by a factor up to 1000 by the FLASH (fast low angle shot) technique. Thus, it is now possible to follow human physiological processes on an MRI film with a frame speed of 5 pictures using a whole-body magnet. Films of speech, tongue movements and the act of swallowing reveal the value of this technique for the functional diagnosis of disease of the oropharynx. Precise imaging of the anatomical and functional situation, especially of soft tissues, is superior to that of previous methods such as ultrasound, X-ray, and endoscopy.

[Voice rehabilitation following total laryngectomy: microvascular laryngeal replacement-plasty (laryngoplasty) instead of voice prosthesis]

Since the introduction of the so-called voice prostheses tracheoesophageal puncture is currently the most widely used surgical procedure for vocal rehabilitation after total laryngectomy. The voice prosthesis renders possible a reliably reproducible voice, which is superior (period of uninterrupted sound production, basal frequency, voice intensity) to the other techniques (esophageal speech, external vibrators, other surgical reconstructive measures), but has the following disadvantages: high initial phonation pressure, formation of granulation tissue around the voice shunt, blockage or leakage of the prosthesis or the voice shunt, displacement of the prosthesis, spontaneous occlusion when the prosthesis is accidentally removed, overtaxing the patients who have difficulties in replacing and cleaning the prosthesis. As an alternative new surgical technique a substitute larynx tube (laryngoplasty) was formed by a microvascular anastomotic forearm flap and connected to the trachea and pharynx in ten patients with extensive (T3-T4) laryngohypopharyngeal carcinoma. All ten patients developed a voice comparable with those of patients who have a voice prosthesis (frequency, voice intensity, period of uninterrupted sound production). An advantage of this graft over the voice prosthesis is that the phonation pressure required is low. While they were still in hospital eight patients learned to speak without using their hands by means of a tracheostomal valve. So far (six months postoperative) this surgical procedure has proved to be a practicable surgical alternative to a voice prosthesis.

Laryngoplasty with a radialis pedicle flap from the forearm: a surgical procedure for voice rehabilitation after total laryngectomy

Tracheoesophageal puncture and insertion of a prosthetic voice device is currently the most widely surgical procedure for vocal rehabilitation after total laryngectomy. The disadvantages of voice prostheses are high initial phonation pressure, formation of granulation tissue around the voice shunt, blockage, displacement of the prosthesis, leakage of the prosthesis or the voice shunt, spontaneous occlusion when the prosthesis is accidentally removed and difficulties in replacing and cleaning the prosthesis. In an effort to avoid these problems, a substitute laryngeal tube (laryngoplasty) was fashioned from a revascularized forearm flap and connected to the trachea and pharynx in seven patients with extensive laryngohypopharyngeal carcinoma. All seven developed a voice comparable with patients fitted with a voice prosthesis. An advantage of this graft is the low phonation pressure required for voice production. Problems with aspiration have not occurred even after radiotherapy. While still in the hospital, five patients learned to speak without using their hands through the use of a tracheostomal valve. Judging by these results, this surgical procedure is a practical alternative to a voice prosthesis.

Anaesthetic management in patients with epidermolysis bullosa dystrophica

Successful anaesthetic management of two patients with severe epidermolysis bullosa dystrophica was accomplished with the use of ketamine-diazepam dissociative anaesthesia in one and brachial plexus block in the other. The classification and pathology of epidermolysis bullosa is considered, and the problems associated with anaesthesia in patients with this disease are discussed.

Spondylolysis and spondylolisthesis. Treatment by internal fixation and bone-grafting of the defect

Eighteen patients who had symptomatic spondylolysis or Grade-I spondylolisthesis, and whose symptoms had not been relieved by non-operative treatment, were operated on using the Buck method for bone-grafting and internal fixation of the defect of the pars interarticularis with screws. There were six male and twelve female patients and the average age was twenty years (range, fourteen to thirty-eight years). The amount of slipping ranged from zero to ten millimeters. After an average period of follow-up of forty-one months (range, twenty-four to seventy-two months), the result was excellent in ten, good in five, and poor in three patients. Thus, a satisfactory result was obtained in 83 per cent of the patients.