[Surgical treatment of the lacrimal apparatus--technics and results]

After a short review of anatomy the clinical and radiological diagnosis of stenoses of the lacrimal duct system are discussed in detail. Microcatheterdacryocystography and high resolution CT are very important in determining the indications for surgery. Microsurgical endonasal dacryocystorhinostomy is preferred for treatment of postsaccal stenoses. It is also the method of choice for one stage definitive therapy of acute lacrimal sac empyema. Surgical reconstruction in cases of presaccal stenoses is difficult and should be handled individually. For intubation of the canaliculi we have developed a special modified pigtail-hollow-probe (Draf-Haag 1981), which reduces damage to the epithelium. If reconstruction of the natural lacrimal duct system is not possible, a conjunctivorhinostomy by Walter's technique is indicated. The different surgical concepts and results are discussed.

[Oncosurgical treatment principles in basalioma and spinocellular carcinoma of the facial skin]

The concept for surgical removal of facial skin neoplasms consists of three components: Sufficient preoperative clinical diagnosis; complete tumor removal; Adequate functional and esthetic reconstruction. For achieving proper diagnosis the collaboration with the dermatologist is highly recommended. The ENT examining microscope allows for better visualisation of structural characteristics. Excisional biopsy should be preferred whenever possible. Out of 97 basal cell carcinomas 25% secondary or thirdly neoplasms have been found. In 81 basal cell carcinomas the visible extent, the real tumor extent in the specimen after fixation and the total excisional area are compared. According to these measurements the following safety margins seem to be recommendable: For small solid or solid-cystic superficial basal cell carcinomas 3-5 mm, for the sclerodermiform or partially undifferentiated basal cell carcinoma 10-20 mm and for basal cell carcinomas involving the bone more than 20 mm. Excising a spinocellular carcinoma a safety margin of at least half of the maximal diameter has proved to be sufficient. The close collaboration with the histopathologist resulted in our department in a simplified economic and safe microscopically controlled excision. The rate of recurrences of 97 basal cell carcinomas was 6.6%. The question of prophylactic lymph-node dissection in combination with the excision of spinocellular carcinomas is discussed.

[Tuberculosis of the head, neck and ear--a rare disease?]

Between 1980 and 1984 we treated 9 patients with tuberculosis of the lymph nodes, middle ear, parotid gland, larynx and sphenoid sinus. Diagnosis is difficult because of the unusual courses of the disease, the special pathways of infection and because tuberculosis is rarely suspected as the diagnosis. The importance of a combined conservative-surgical therapy is stressed.

[Quantitative functional scintigraphy of the salivary glands--clinical possibilities and current indications]

A special background subtraction in dynamic scintigraphy of the salivary glands enables the production of net-time-activity-curves and the calculation of quantitative parameters of each gland. Regional functional differences within a single gland are shown by phase and gradient images. The physiological kinetics of the tracer and its modifications in different diseases of the glands (acute and chronic inflammation, tumours, Sjögrens-Syndrome) are analyzed in 367 patients.

[ENT surgery and laboratory medicine--the modern aspects of cooperation]

The value and application of a multiphase screening programme of preoperative laboratory investigations on ENT patients is described and assessed. Appropriate laboratory investigation should be chosen. The methods of investigation should provide information about the patient's general condition, should identify disease which has escaped clinical assessment, which is not connected with the underlying disease, but which could severely handicap a patient undergoing surgery. They are also designed to assist in the medical screening of the general population. The programme includes tests of organ function and of metabolism. The frequency of abnormal laboratory values (less than 2.5% at to longer end of the normal distribution curve or above 5% at the other) was 7.8% for blood sugar, 2.9% for serum creatinine, 4.5% for urea, 11.6% for uric acid in men and 4.8% in women, 9.8% for serum cholesterol, 2.9% for SGOT in men and 20.8% for triglycerides. Tests included in the haemostasiological study were the basic coagulation testing programme (PTT, Prothrombin Time, Thrombin Time and Fibrinogen). Inherited and acquired blood disorders are detected through the full coagulation test programme and assay of the specific coagulation factors and fibrin degradation products. We diagnosed 11 inherited blood disorders in 10,000 patients put through the above screening programme. The problems of diagnosis and therapy of antibody haemophilia are demonstrated by an example of antibody haemophilia of factor VIII.

[Differential diagnosis of the saddle nose and perichondritis of the outer ear - the von Meyenburg-Altherr-Uehlinger syndrome (panchrondritis)]

Basing on the description of a case treated by the authors, the von Meyenburg-Altherr-Uehlinger syndrome is illustrated with its manifold symptoms and the resulting difficulties in diagnosis. Besides the signs of involvement of the eyes, joints, heart and vascular system, the symptoms caused by affection of the cartilage of the ear, nose, trachea and bronchi are important for the ENT surgeon. Aspects of differential diagnosis are discussed. The aetiology and pathogenesis of the syndrome are still unknown. Therapy is symptomatical with steroids and, in special cases, with immunosuppressive drugs.

[Surgical treatment of benign and malignant lip tumors]

Benign tumors of the lips are resected aiming the least visible scarring. In cases of malignant tumors spreading on the surface of the lower lip we succeeded reconstructing it after complete excision of vermillion using tongue flaps. This was performed in two stages. The Meyer technique is to be preferred from functional as well as from esthetic point of view in cases where the tumor has required medium or subtotal excision of the lower lip. In tumors of the upper lip it may be used the other way round. Larger lip defects have to be managed by major regional flaps. Some examples are demonstrated.

[Possibilities of reconstruction by de-epithelization (author's transl)]

By definition de-epithelization is a technique by which a graft or a flap is thinned out of the split thickness or full thickness skin layer. The underlying fat tissue is thus covered more or less by corium only. The indications for this procedure are as follows: 1. A subcutaneous defect. 2. Resurfacing defects in a cavity (for example in the pharynx) 3. Subcutaneous implantation of a flap pedicle. The advantages of de-epithelization are: 1. Widening the scope of surgical technique. 2. In many cases second surgery can be avoided. 3. The way from the donor to the recipient site is shorter. 4. A large regional flap can be used not only for reconstruction of the superficial defect but also for subcutaneous filling of a hole. Possible complications are disturbances in the nutrition of the flap and formation of subcutaneous cysts and fistulas which may lead to infections. It is obvious that careful assessment of the indication and precise technique performance are mandatory. Out of 221 flap procedures done in our department since February 1979 we used the de-epithelization technique in 7 cases (3.2%).

[Diagnosis and therapy of fibromatosis in head and neck region (author's transl)]

Fibromatosis is a heterogenous group of soft tissue neoplasias, only some forms of which occur in the head and neck region. In the pathological classification it takes place between the fibroma and fibrosarcoma. With nodular fasciitis, it's subspecies myositis proliferans and aggressive fibromatosis exist differential diagnostic difficulties, especially as it's difficult to exclude fibrosarcoma. The benign myositis proliferans gives an impression of a malignant process by it's rapid proliferation, cell-polymorphia and high mitotic activity. The monomorphous histological picture and the slower proliferation of the aggressive fibromatosis, however can simulate a benign tumor, although thought to be semimalignant. 3-case-reports point out these characteristics. Complete excision is the therapy advised for all fibromatosis. In aggressive fibromatosis a large enough healthy area is the best condition to prevent recidives.

[Problems of laryngeal reconstruction following perichondritis of the larynx (author's transl)]

The surgical reconstruction of the larynx following laryngeal perichondritis is an uncommonly published subject. Three cases with special problems are presented. The main points of management to be remembered are that: 1. the complete removal of all necrotic tissue is essential for the success of surgical rehabilitation; 2. the restoration of respiration, deglutition and phonation can be achieved with use of regional skin and composite skin and cartilage flaps.

[Facial neuralgia after Caldwell-Luc-Operation - Prophylaxis and therapy]

The postoperative neuralgia occurring after Caldwell-Luc-Operation is a common complication. It is important that the consequent surgery on the maxillary sinus does not make a preexisting neuralgia worse. On the other hand the occurrence of the postoperative pain-syndrom should be avoided. There are several possibilities in order to achieve this aim: 1. A precise choice of surgery and correct indication in every case. 2. Surgical diagnosis and therapy should go hand in hand according to the individual case. The operative technique in order to avoid the postoperative painsyndrom after Caldwell-Luc-Operation as well as the microsurgical neurolysis of the infraorbital nerve as a therapy of the neuralgia following a procedure has been discussed.

Insertion of ventilation tubes into the medical ear: results and complications. A seven-year review

From 1969 to 1976 in the University ENT Clinic Mainz, a total of 677 patients received insertion of ventilation tubes into the eardrum. Three hundred eighty-five cases were able to be statistically evaluated. These were 80 adults and 305 children, 37 of these with cleft palate. All together a total of 875 operated ears were considered.

[Intracranial-intratemporal anastomosis of the facial nerve (author's transl)]

Using the microsurgical technique during the exstripation of the acustic neuroma in the otosurgical as well as neurosurgical approach of the procedure, it was possibel to achieve not only a considerable drop in the mortality rate, but also a preservation of the facial nerve. Our technique of intracranial/intratemporal anastomosis allow in cases with deep defects of the facial nerve in the cerebellopontine angle a relatively reliable rehabilitation of the nerve at the time of a tumor resection. The success is based on the teamwork between ENT- and Neurosurgeons. 8 patients were operated until now. In all cases the satisfactory return of the face motoric has been noted within 3/4-11/2 years after the operation.

[Experiences with fibrinogen glue in ENT surgery (author's transl)]

Detailed informations are given about the application technique of a biological tissue adhesive based on fibrinogen clotting after a review about its development and the possibilities of application till now. From experiences in over 50 cases the author found good results by using the Human Fibrin adhesive in the ENT-surgery, especially in the surgery of the middle ear, the surgery of the nose, in plastic and plastic-reconstructive surgery, the treatment of fractures of the skull base in the area of the rhino- and otobasis, especially of the sphenoidal sinus, the covering of defects of the oral mucosa and finally to compensate outline defects in the facial area.

[The reconstruction of the hypopharynx and the cervical esophagus (author's transl)]

Since 1973 16 reconstructions of the hypopharynx and cervical esophagus were performed. The restoration of swallowing was achieved in 7 cases after partial resection of the pharynx, 9 times after total laryngo-pharyngectomy and twice after laryngo-pharyngo-esophagectomy. The indication for surgery and criteria for the surgical methods to be applied are discussed. It is possible to combine the reconstruction of the pharynx with building up a neoglottis with Staffieri's technique for restoring voice function. As a one stage procedure to the hypopharynx and cervical esophagus after total laryngo-pharyngectomy the methods of Loré as well as the reconstructive techniques using regional flapes are useful. The larynx-hypopharynx-esophagusresection of Ong and Lee (1960) whould be prefered if the rumour involves the orifice of the esophagus, because an extensive submucosal growth of the carcinoma is to be expected. A two stage procedure is preferred when recurrences of cancer especially after x-ray therapy have to be treated, or a bilateral radical neck-dissection has to be done. This concept offers smaller risks and is finally also faster. A method is demonstrated using a bridge flap for the protection of the carotid artery and the reconstruction of the posterior wall of the pharynx using a deltopectoral flap for rebuilding the lateral and the anterior walls of the pharynx.

[Anaesthesiological and ENT surgical aspects in long operations (author's transl)]

In ENT surgery due to the differential anatomy of the operation area, radical tumour surgery, necessary plastic surgery and covering of resulting defects, plus efforts in maintenance and reconstruction of important functions the resulting operations are frequently lengthy. In 27 patients whose operations required longer as 10 hours the problems of anaesthesia and operation were analysed and discussion from various angles. With close teamwork between surgeon and anaestheist in the planning and carrying out of such procedures and in the postoperative care it is possible to eliminate higher risks due to the prolonged operation time. The perioperative mortality rate within a time period of 4 weeks was in our case 0%.

[The width of the internal auditory meatus in Bell's palsy. A radiological-tomographical study (author's transl)]

44 patients with ischemic facial paralysis were studied and tomograms made of both petrous bones. An attempt was made to establish the normal averages of various portions of the internal auditory meatus (fundus, middle, porus) from frontal projections. In addition, a comparison of each portion of the internal auditory meatus was made between diseased and healthy sides. Of patients studied, one third showed a narrowing of the internal auditory meatus on the involved side. A correlation between narrowing of the bony internal auditory meatus and the occurrence of an ischemic facial paralysis could not be established. However, such cannot be totally excluded as a contributing factor in the origin of a Bell's palsy.