[Frontal sinus impression fracture as a collision sequelae in football]

4 soccer accidents, causing the rare case of impression fracture of the frontal sinus, are introduced as soccer-specific lesions, which are caused by head-to-head collisions, being due to heading-maneuvers. Mostly the right frontal sinus was hurt. The indication for an operation is the obvious dislocation of the osseous fragments. Primary intentions for an intervention are the precise reconstruction of the anterior wall of the frontal sinus because of esthetic reasons and a permanent drainage in order to avoid late complications as for instance mucopyoceles, if the infundibulum has been damaged. The therapy of choice is the osteoplastic frontal sinus operation, using a bicoronary incision.

[Aneurysmal bone cyst of the petrous bone. A rare cause of recurrent bacterial meningitis]

Occult malformations of the skull base are very rare disorders which cannot initially be diagnosed clinically. They become first symptomatic, if complications arise. The most frequent clinical manifestation is a recurrent bacterial meningitis. Based on the unique case of a presumably congenital aneurysmal bone cyst of the petrosal bone, which imposed clinically as hearing loss and recurrent bacterial meningitis, we have evaluated the extensive literature on this theme. Considering mostly atypical clinical findings, solely coronal thin-section computed tomographic scans of the skull base allow a reliable diagnosis. The possible risks of this investigation (necessary sedation up to insufflation anesthesia and the radiation exposure of the child's lens) are justifiable and subordinate to the diagnostic importance.

[Reconstruction of lacrimal ducts]

For reconstruction of lacrimal drainage after injury of tumour resection indications, surgical technique and results of five surgical procedures are presented: primary suture with splinting, conjunctivorhinostomy, endonasal dacryocystorhinostomy, Heermann tube and mobilisation of nasolacrimal duct. Performing these techniques, solitary or in combination, one achieves almost a good lacrimal drainage. The results of our retrospective study are based upon a combination of subjective and objective findings. Success rate was 96% for direct suturing of the tear ducts with intubation, 100% for conjunctivorhinostomy, 96% for endonasal dacryocystorhinostomy in case of postsaccal stenosis, 83% for Heermann/Jones tube and 100% for relocation of the nasolacrimal duct.

[Foreign bodies of the esophagus and upper gastrointestinal tract in childhood]

In a retrospective study we evaluated 49 endoscopies performed under suspicion of a foreign body in the oesophagus or upper gastrointestinal tract. In 27 cases a foreign body was easily removed. One child had to undergo a cervical oesophagotomy as a result of a chronically incarcerated foreign body. Because of the very low complication rate of endoscopy and a much higher risk of complications due to unknown foreign bodies, early endoscopic diagnosis is recommended even if the foreign body is only suspected.

Temporal bone fractures: high resolution CT

Apart from midfacial traumas, laterobasal fractures are the most common skull base injuries the ENT surgeon has to deal with. These fractures often appear in combination with more or less extensive further skull or brain injuries. In these cases interdisciplinary co-operation with the neurosurgeon is necessary. Today, development of high resolution computed tomography makes it possible to define priorities in treatment of these patients exactly.

[Personal experience with Ionocem in head- and neck surgery]

Ionomeric bone bond cement (Ionocem) is a new alloplastic bone replacement material, which was used by us for functional and aesthetic purposes in surgery of the head and neck. We have used the cement 44 times (in 43 patients) for repair of skull and mid-face trauma, reconstruction of defects after tumor removal and for aesthetic augmentation. Ionocem was distinguished by its ready shaping on existing bony structures, its adaptation of bone fragments and bone implants without gaps and its help in avoiding ancillary procedures requiring autogenous grafts. Complications occurred in 22 patients, with most involving swelling, seromas, granulation, fistulas and sequestration which occurred after unsuitable indications or application.

[Endonasal microsurgical treatment of lacrimal duct stenoses. Indications, technique and results]

In a retrospective study we examined the indications, results and complications of endonasal microscopic dacryocystorhinostomy. Eighty-five operations were evaluated. Surgical success was proven in 83% for all indications using a combination of subjective judgement and objective findings. For the so-called classic indications--postsaccal stenosis, functional stenosis dacryolith and acute empyema--the operation was successful in 91% of cases. There were no permanent side effects.

[Results, complications and efficacy of micromediastinoscopy]

In a retrospective study we examined all 72 patients who underwent a mediastinoscopy using the surgical microscope described by Meuser in 1968. A total of 74 operations was performed. In only 3 cases was there a false-negative result. Test sensitivity was 95%, specificity 100% and effectiveness 96%. Complications involved 2 cases of pneumothorax (for which no further therapy was necessary), 1 case of bleeding from a branch of the brachiocephalic trunk and 1 case of persistent lymphorrhagia with chylothorax, which was stopped by repeat mediastinoscopy. Preconditions for mediastinoscopy to minimize complications and false-negative results are: preoperative CT of the thorax, good cooperation with an anaesthesiologist, use of a microscopic and other special instruments and intraoperative frozen sections of tissue biopsies.

[Simultaneous occurrence of an acoustic neurinoma and a glomus tympanicum tumor in a patient. An unusual constellation and problematic surgical task]

We present the case of a 65-year-old woman who was found to have a concurrent ipsilateral acoustic neuroma and glomus tympanicum tumor. Both tumors were removed in one operation. The acoustic neuroma was removed via the translabyrinthine approach because of preoperative deafness while the glomus tumor was found only during the operation to remove the neuroma. A preoperative biopsy was not associated with significant bleeding while microscopic examination of the biopsy tissue indicated only chronic infection.

[Bilateral Gradenigo syndrome--on the value of an integrated therapy concept including hyperbaric oxygenation and chronic destructive inflammation of the skull base]

The case of a 30-year-old female with bilateral Gradenigo's syndrome is presented in order to detail commonly applied therapy. In particular, the importance of a comprehensive therapeutic approach is emphasized that includes such adjuvant therapeutic options as hyperbaric oxygenation and the administration of specific immunoglobulins. Indications, therapeutic benefits and limitations of treatment modalities are discussed in relationship to current concepts of therapy.

[Esophagotracheal fistula of the cervico-thoracic area--problem solution using a combined trans-cervical and transthoracic approach]

Closure of oesophagotracheal fistulae in the cervicothoracic region using a cervical approach often fails. We report a patient with carcinoma of the larynx who underwent pharyngolaryngectomy, postoperative radiotherapy and several operations for reconstruction of the hypopharynx and cervical oesophagus elsewhere. Finally we were asked to close an oesophagotracheal fistula in the cervicothoracic region. We were successful using a pectoralis major muscle flap via a combined transcervical-transthoracal approach. This interdisciplinary procedure seems to be the method of choice in difficult cases of achieving safe closure of fistulae in this region.

[Complications of endonasal micro-endoscopic ethmoid bone operation]

We examined the frequency and site of major complications after intranasal micro-endoscopic ethmoidectomy. Injury of the orbital periostium was significantly more frequent on the right than on the left side, but there was no side predominance for damage to the dura mater. Surgery on the lamina papyracea and the lateral wall of the sphenoid sinus is more dangerous on the side on which the surgeon stands during the operation. The use of the microscope, the endoscope and preoperative CT scan of the paranasal sinuses helps to avoid major complications.

Surgical treatment of facial dog bite injuries in children

Although today most injuries of face and head are the result of car and motorcycle accidents, dog bites are a frequent cause of facial injuries in children. In recent years, general guidelines have been established concerning the surgical treatment of facial dog bite injuries in children. We have seen 16 children with such lesions at our hospital in the last 4 years. All children have been treated surgically, under general anaesthesia, by primary closure of the wound with interrupted sutures after having adapted the margins by subcutaneous sutures. In addition, all children have been evaluated 3 months-5 years after the accidents in order to objectify the results of our treatment. Special attention has been attached to the functional and aesthetic outcome. In all cases, we saw good-to-excellent results. Based on this experience we suggest a clinical classification of these injuries in regard to a special therapeutic regime for each stage. In this way, guidelines may be established for the surgeon dealing with these injuries.

[Parotidectomy: functional and esthetic results]

We report a retrospective study of 154 patients after parotidectomy. The patients were examined immediately and on average about 40 months after the operation. The emphasis of the examination was to assess both functional as well as aesthetic results. The function of the facial nerve was evaluated by Stennert's score. We found a median score of 20% 3.3 days after operation. The late postoperative results (34.3 months after operation) indicated that 91% of the patients had no paresis. There was no significant difference between superficial parotidectomy and total parotidectomy in regard to the aesthetic result. The decision for partial or total parotidectomy should be based exclusively on pathological and oncological considerations.

[Systematic indications of various free transfer flaps in the area of the head and neck]

Many microsurgical free flaps have been described to tackle various problems in the head and neck. The authors present a system of indications which has proved to be suitable as judged by the functional and cosmetic results obtained. The harvesting of these flaps requires versatile training in surgical techniques for the different anatomical areas. This system of indications comprises the free fasciocutaneous forearm flap, jejunal loops, the fasciocutaneous parascapular flap, iliac crest flaps with vascularized bone and the parascapular cutaneous, latissimus dorsi osteomyocutaneous double flap.

[Facial injuries caused by dog bites in childhood. Clinical staging, therapy and prevention]

Dog bite injuries are a frequent cause of facial injuries in childhood. Between 1986 and 1990 we treated 16 children with facial dog bite injuries. Based on these experiences we suggest a clinical classification, corresponding therapeutic rules and prophylactic possibilities, summarized according to the literature. It is our aim to establish guidelines for the physician concerned with the therapy of these injuries, and advice to involved families.

[Surgical treatment of malignant tumors of the paranasal sinuses with involvement of the base of the skull]

After 18 years of close cooperation between ORL and neurosurgery in the treatment of the base of the skull, the authors present their surgical conception and technique for the treatment of malignant tumors of the paranasal sinuses involving the base of the skull. Three basically different surgical procedures are possible: 1. Extracranial partial resection of the anterior base of the skull sparing the contents of the orbit. 2. Radical revision of superior maxilla, ethmoid bone, and base of the skull including exenteratio orbitae. 3. Combined intra-extracranial approach. An interdisciplinary cooperation and the combination of macro- and microsurgery will be more successful with respect to survival chances, functional and esthetic results.

[Yaws: a rare case of an "invasively growing" tumor of the maxillary sinus]

Yaws is a treponematosis which is rare in Europe. Tertiary stages may present with tumor-like lesions predominantly in the face. These manifestations are called rhinopharyngitis mutilans and goundou. A 40-year-old woman with goundou is presented.

Surgical rehabilitation of facial nerve

The management of facial nerve lesions using microsurgical techniques should be part of the armamentarium of surgeons managing head and neck problems. One has to differentiate between techniques for repair of the nerve itself and secondary reconstructive operations. Direct nerve reconstruction, indirect nerve reconstruction and combined procedures are discussed in detail. Secondary reconstructive methods are indicated if repair of the nerve itself is not possible. The results of 31 cases of facial nerve rehabilitation are presented.

[Laterocaudal approaches to the clivus]

The different lateral approaches to the skull base (including the clivus) are subsumed under the term infero-lateral approaches, and include: 1. The cervical approach. 2. The direct lateral approach. 3. The postero-inferior approach. Indications and technical details are discussed, and a few examples are demonstrated. The inclusion of microsurgery improves the results as regards survival, function and esthetics. Reconstructive surgery must be included in the rehabilitation of these difficult surgical problems. In special cases this problem can be better solved by co-operation between ENT and neurosurgeons.