Continuous intraoperative neuromonitoring of the facial nerve predicts postoperative facial palsy in parotid surgery: a prospective study

PURPOSE

Facial palsy (FP) is the most significant complication of parotidectomy. Currently, the use of intermittent intraoperative neuromonitoring (iIONM) in parotid surgery facilitates nerve detection, which is paramount to nerve protection. Continuous IONM (cIONM), as applied in thyroid surgery, enables real-time information on electrophysiological nerve status through continuous nerve stimulation, thereby allowing consequent amplitude analysis. To date, the application of cIONM in parotid surgery has not been noted in literature.

METHODS

We performed parotidectomies with anterograde facial nerve visualization using cIONM in 32 consecutive patients in a prospective study (German Register of clinical studies-DRKS 00011051) during the period October 2016 to January 2020. After the facial trunk had been exposed, an atraumatic stimulation electrode was placed and the nerve was stimulated at 3 Hz, at a low threshold (0.62 ± 0.06 mA), for the entire duration of the preparation. Selected electrophysiological parameters were collected and compared to postoperative facial nerve function, measured by the House-Brackmann grading system.

RESULTS

In the post hoc analysis, a significant correlation between a drop in amplitude (< 50% of the "baseline" amplitude) and postoperative FP was recorded (p = 0.001). True positive prediction of FP was noted in 14 out of 16 patients and true negative in 10 out of 16. The sensitivity was 87.5% (AUC 0.75), with a high negative predictive value of 83.3%.

CONCLUSION

cIONM has significant value in predicting postoperative FP in parotidectomy. Future development of an acoustic/optic warning system in IONM devices could prevent nerve injury in real time.

[Update on asthma 2024 - what the ENT specialist needs to know]

The lifetime prevalence of 8.6% of asthma in Germany reflects the high medical and socioeconomic impact of the disease. Asthma treatment goals have changed during the last decades: from symptom control to symptom prevention, with highly effective, disease-modifying anti-asthmatic drugs (DMAADs) aiming at asthma remission. In order to achieve this goal, phenotyping of patients (including an evaluation of allergies and type 2 biomarkers) is crucial for personalized treatment. The identification and effective treatment of concomitant diseases, such as allergic rhinitis or chronic rhinosinusitis with nasal polyps (CRSwNP), plays a major role for successful treatment. This underlines the importance of interdisciplinary collaboration of otolaryngologists and respiratory physicians in the management of patients with asthma. This CME article informs the reader about current guidelines on the diagnosis and treatment of asthma, focusing on clinically relevant recommendations for ENT physicians.

Role of prior intratympanic gentamicin and corticosteroids therapy on speech understanding in patients with Menière's disease after cochlear implantation

AIM

Intratympanic injection of corticosteroids (ITC) and gentamicin therapy (ITG) are widely used treatments for vertigo in Meniere's disease (MD). Even though studies show good results after cochlea implantation (CI) in MD patients when compared to non-MD groups, there is no indication on the effect of ITC and ITG prior to CI on hearing after CI. This study compares the post-operative hearing of CI patients with and without MD and patients who have received ITG or ITC prior to CI.

METHODS

In a retrospective case control study, adult patients with MD who received CI from 2002 till 2021 were compared to a matched control group of CI patients without MD. Patients with prior ITC/ITG were extracted from MD group. Pre-operative audiological results were measured and trends across post-operative monosyllabic word recognition score at 65 decibels (WRS65CI) at switch-on, 3-6 months, 1 year and last yearly value were analyzed across all groups.

RESULTS

28 MD ears were compared with 33 control ears. From MD ears 9 had received ITG and 6 ITC prior to CI. WRS65CI increased significantly with time within MD and control groups, but no difference in WRS65CI was found between these 2 groups. ITG ears showed fluctuating WRS65CI after CI with no change across time, while ITC ears showed significant increase in trend of WRS65CI values across time.

CONCLUSION

MD and non-MD patients showed comparable hearing results after CI. Prior ITC might positively influence hearing preservation after CI in MD patients whereas ITG group showed fluctuating hearing.

[Persistent olfactory impairment after COVID-19-recommendations of the Working Group on Olfactology and Gustology of the German Society of Oto-rhino-laryngology, Head and Neck Surgery]

This article does not intend to comprehensively review the existing literature on coronavirus disease 2019 (COVID-19)-associated smell disorders, but aims to summarize scientific evidence for otorhinolaryngological practice and provide recommendations for diagnosis and treatment of persistent smell disorders following COVID-19.

RNAi-Mediated Knockdown of Cottontail Rabbit Papillomavirus Oncogenes Using Low-Toxicity Lipopolyplexes as a Paradigm to Treat Papillomavirus-Associated Cancers

The cottontail rabbit papillomavirus (CRPV)-associated VX2 carcinoma of the New Zealand White rabbit serves as a model system for human papillomavirus (HPV)-associated head and neck squamous cell carcinomas (HNSCCs). The aim of this study was to evaluate the tumor-inhibiting effect of RNAi-mediated knockdown of the CRPV oncogenes, E6 and E7, using siRNA-loaded lipopolyplexes (LPPs). VX2-carcinoma-derived cells were cultured for up to 150 passages. In addition, CRPV E6 and E7 oncogenes were transiently expressed in COS-7 cells. Efficiency and safety of LPPs were evaluated in both VX2 cells and the COS-7 cell line. Both of these in vitro CRPV systems were validated and characterized by fluorescence microscopy, Western blot, and RT-qPCR. Efficient knockdown of CRPV E6 and E7 was achieved in VX2 cells and COS-7 cells pretransfected with CRPV E6 and E7 expression vectors. Knockdown of CRPV oncogenes in VX2 cells resulted in reduced viability, migration, and proliferation and led to a G0/G1 block in the cell cycle. CRPV E6 and E7 siRNA-loaded LPPs could represent promising therapeutic agents serving as a paradigm for the treatment of papillomavirus-positive cancers and could be of value for the treatment of CRPV-associated diseases in the rabbit such as papillomas and cancers of the skin.

Generation of a Syngeneic Heterozygous ACVRL1(wt/mut) Knockout iPS Cell Line for the In Vitro Study of HHT2-Associated Angiogenesis

Hereditary hemorrhagic telangiectasia (HHT) type 2 is an autosomal dominant disease in which one allele of the ACVRL1 gene is mutated. Patients exhibit disturbances in TGF-beta/BMP-dependent angiogenesis and, clinically, often present with severe nosebleeds as well as a reduced quality of life. The aim of our study was to use CRISPR/Cas9 to knockout ACVRL1 in normal induced pluripotent stem cells (iPSCs) and evaluate the effects on TGF-beta- and BMP-related gene expression as well as angiogenesis. The CRISPR/Cas9 knockout of the ACVRL1 gene was carried out in previously characterized wild-type (ACVRL1^wt/wt) iPSCs. An HHT type 2 iPS cell line was generated via a single-allele knockout (ACVRL1^wt/mut) in wild-type (ACVRL1^wt/wt) iPSCs, resulting in a heterozygous 17 bp frameshift deletion in the ACVRL1 gene [NG_009549.1:g.13707_13723del; NM_000020.3:c.1137_1153del]. After the generation of embryoid bodies (EBs), endothelial differentiation was induced via adding 4 ng/mL BMP4, 2% B27, and 10 ng/mL VEGF. Endothelial differentiation was monitored via immunocytochemistry. An analysis of 151 TGF-beta/BMP-related genes was performed via RT-qPCR through the use of mRNA derived from single iPS cell cultures as well as endothelial cells derived from EBs after endothelial differentiation. Differential TGF-beta/BMP gene expression was observed between ACVRL1^wt/wt and ACVRL1^wt/mut iPSCs as well as endothelial cells. EBs derived from CRISPR/Cas9-designed ACVRL1 mutant HHT type 2 iPSCs, together with their isogenic wild-type iPSC counterparts, can serve as valuable resources for HHT type 2 in vitro studies.

Abdominal ultrasound in head and neck squamous cell carcinoma staging: yes or no?

PURPOSE

Abdominal ultrasound is a diagnostic staging procedure for distant metastases in head and neck squamous cell carcinoma (HNSCC). However, currently performed abdominal staging procedures do not follow consistent standards. Therefore, this retrospective study on 498 patients aimed at investigating on abdominal ultrasound as a staging procedure in HNSCC.

MATERIALS AND METHODS

A retrospective analysis of 498 head and neck cancer patients treated in our Department of Head and Neck Surgery between 2008 and 2015 was performed. Disease-related data were collected over a mean follow-up time of 30.3 months, and results of abdominal ultrasound were analyzed.

RESULTS

426 patients received abdominal ultrasound as a staging procedure. 7% (29) were suspicious for metastases. In 19 cases (66%), the detected abnormalities were masses of the liver. In four patients, abdominal metastases were confirmed at the time of initial diagnosis. 16 patients developed abdominal metastases in the course of the disease (on average 623 days after initial diagnosis). 19 out of 20 patients with abdominal metastases had an N2/N3 cervical lymph node status. In this study, the negative predictive value of abdominal ultrasound for HNSCC staging was 99.03%, while the positive predictive value yielded 5.88% (N2/N3-patients).

CONCLUSION

Only in patients with locally advanced lymph-node-status (N2/N3), abdominal ultrasound can be useful as a staging investigation to exclude abdominal metastasis in HNSCC patients. For N0/N1 patients, abdominal ultrasound might be dispensed. Of note, in case of a positive result, further diagnostic procedures are mandatory.

[Treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) with monoclonal antibodies (biologics): S2k guideline of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), and the German College of General Practitioners and Family Physicians (DEGAM)]

Monoclonal antibodies (so-called biologics) can be prescribed for chronic rhinosinusitis with nasal polyps (CRSwNP) within the scope of their market authorization. However, their prescription is limited to severe CRSwNP without disease control, whereby certain requirements must be met. Dupilumab, omalizumab, and mepolizumab have currently gained market authorization, with adequate evidence for their efficacy and safety available in the literature. It can be assumed that other biologics will be approved for this indication in the future. The severity of disease and the efficacy of treatment should be assessed objectively and subjectively before treatment initiation and after an appropriate duration, respectively. The documentation sheet proposed in this guideline chapter can be used for the assessments. In the presence of relative contraindications, a treatment should only be initiated after differentiated consideration by an experienced physician in the sense of a case-by-case decision. In summary, this guideline chapter aims to contribute to high-quality care of adult patients with these therapies in view of the increasing evidence for treatment with these substances and the increasing number of market authorizations of different biologics.

Impact of Bepanthen® and dexpanthenol on human nasal ciliary beat frequency in vitro

BACKGROUND

Dexpanthenol-containing ointments/fluids are recommended to restore impaired nasal mucosa. To date, there are no data about the influence of dexpanthenol or formulations including dexpanthenol on ciliary beat frequency (CBF) of nasal epithelial cells.

METHODS

We tested the ciliary beat frequency of human nasal epithelial cells in RPMI 1640 cell solution using in vitro high-frequency video microscopy every 60 s over a period of 15 min (min). Bepanthen^® solution and dexpanthenol in two clinically relevant concentrations (1.67% and 3.33%) were added to the cells. Addition of sterile water served as control group. To get a better overview, the measurements after 1 min, 5 min and 15 min were combined.

RESULTS

The CBF in the control group (n = 17) after 15 min was 7.3 ± 2.6 Hz. In comparison, the CBF after 15 min was 1.8 ± 1.0 Hz in the 3.33% Bepanthen^® group (n = 17) and 3.2 ± 1.2 Hz in the 1.67% group, which was statistically significantly lower in both groups (p < 0.001). With regard to the dexpanthenol group (n = 17) a CBF of 6.0 ± 2.6 Hz with 3.33% and 6.1 ± 2.4 Hz with 1.67% dexpanthenol, was detected, which was again statistically significantly lower (p = 0.06) compared to the control group except CBF at 15 min with 1.57% (n = 17; p = 0.04). In general, the effect on CBF was less pronounced with dexpanthenol compared with Bepanthen^® with a statistically significant difference between the two formulations. The results were verified by calculating an analysis of variance (ANOVA).

CONCLUSIONS

Bepanthen^® as an ointment, solution or inhalation is commonly used in ENT for mucosal care. Our results have shown that both substances reduce CBF in clinically relevant concentrations, although the effect was more pronounced with Bepanthen^® compared to dexpanthenol solution, which could be related to additives or change of physical properties in the solution. Further research is needed to assess potential clinical relevance.

Olfactory Dysfunction: Etiology, Diagnosis, and Treatment

BACKGROUND

Disorders of the sense of smell have received greater attention because of the frequency with which they occur as a symptom of SARS-CoV-2 infection. Olfactory dysfunction can lead to profound reduction in quality of life and may arise from many different causes.

METHODS

A selective literature review was conducted with consideration of the current version of the guideline issued by the Association of the Scientific Medical Societies in Germany.

RESULTS

The cornerstones of diagnosis are the relevant medical history and psychophysical testing of olfactory function using standardized validated tests. Modern treatment strategies are oriented on the cause of the dysfunction. While treatment of the underlying inflammation takes precedence in patients with sinunasal dysosmia, olfactory training is the primary treatment option for other forms of the disorder. The prognosis is determined not only by the cause of the olfactory dysfunction and the patient's age, but also by the olfactory performance as measured at the time of diagnosis.

CONCLUSION

Options for the treatment of olfactory dysfunction are available but limited, depending on the cause. It is therefore important to carry out a detailed diagnostic work-up and keep the patient informed of the expected course and prognosis.

Savor the flavor: A randomized double-blind study assessing taste-enhanced placebo analgesia in healthy volunteers

Placebo effects substantially contribute to analgesic treatment outcomes and might be leveraged to enhance gold-standard treatments. The taste of oral medications has been proposed to boost placebo effects. Here, we aimed at estimating how far the taste of an oral medication enhances placebo analgesia. We conducted a randomized, double-blind, between-group, single-visit study, with pre-treatment baseline. Over the course of three substudies, 318 healthy volunteers (297 included) were tested in a clinical trial setting. Participants were subjected to experimental tonic cold water pain (cold pressor test) before and after receiving taste-neutral (water), or bitter (quinine), or sweet (saccharin), or no placebo drops. Pre- versus post-treatment changes in area under the pain rating curve, the main outcome, indicated that placebo treatment showed a small analgesic effect versus no treatment. Added taste induced placebo enhancement in the very small effect size range, but accounted for a substantial portion of the overall placebo effect. No noteworthy advantage of sweet over bitter placebo was observed. An exploration of heart rate (HR) recordings indicated that placebo treatments were associated with an increase in peak HR-response to cold water, but these were not associated with placebo analgesia at an individual level. Placebo treatments were associated with minimal side effects. These results indicate that added taste may be an easy-to-implement, cost-effective, and safe way to optimize treatment outcomes and that taste-neutral preparations may reduce placebo-related outcome variance in clinical trials. Further studies are needed to test if these findings can be translated into clinical scenarios.

Phytomedicine ELOM-080 in Acute Viral Rhinosinusitis: A Randomized, Placebo-Controlled, Blinded Clinical Trial

BACKGROUND

ELOM-080 is a phytomedicine approved for the treatment of acute and chronic inflammatory diseases of the respiratory tract, sinusitis, and bronchitis in particular. This prospective, randomized, placebo-controlled, double-blind clinical trial was conducted to assess efficacy and safety of ELOM-080 in the treatment of acute viral rhinosinusitis (AVRS).

METHODS

Patients with AVRS received oral treatment (4 × 1 capsule per day) with either ELOM-080 or matching placebo. Primary endpoints were the change in major symptom score (MSS) after 7 and 14 days of treatment assessed by the investigator (MSS_INV ). Secondary endpoints were changes in MSS assessed by the patients (MSS_PAT ), olfactory function (12-item Sniffin' Sticks), 20-Item Sino-Nasal Outcome Test (SNOT-20 GAV; German adapted version), influence of treatment on viral load, and safety.

RESULTS

Four hundred and sixty-three patients were randomized. At day 4, subjective burden of disease (MSS) was significantly ameliorated compared to placebo (p = 0.012). During the first treatment week MSS scores improved about 1 day earlier, and 3 days earlier in the second week. Effect with ELOM-080 on mean MSS_INV was statistically significantly superior to placebo at visit 3 (p = 0.016) and visit 4 (p = 0.014). In chemosensory testing identification scores improved comparably in both treatments. The improvement of the SNOT-20 GAV was more pronounced in ELOM-080 patients. Treatment with ELOM-080 indicated a potential for decreasing viral load. Both treatments were well tolerated.

CONCLUSION

ELOM-080 improves the burden of AVRS significantly in comparison to placebo, remission of symptoms occurred 3 days earlier. The results confirm the efficacy and safety of ELOM-080 for treatment of AVRS.

LEVEL OF EVIDENCE

1 Laryngoscope, 2022.

The importin beta superfamily member RanBP17 exhibits a role in cell proliferation and is associated with improved survival of patients with HPV+ HNSCC

Background

More than twenty years after its discovery, the role of the importin beta superfamily member Ran GTP-binding protein (RanBP) 17 is still ill defined. Previously, we observed notable RanBP17 RNA expression levels in head and neck squamous cell carcinoma (HNSCC) cell lines with disruptive TP53 mutations.

Methods

We deployed HNSCC cell lines as well as cell lines from other tumor entities such as HCT116, MDA-MB-231 and H460, which were derived from colon, breast and lung cancers respectively. RNAi was used to evaluate the effect of RanBP17 on cell proliferation. FACS analysis was used for cell sorting according to their respective cell cycle phase and for BrdU assays. Immunocytochemistry was deployed for colocalization studies of RanBP17 with Nucleolin and SC35 (nuclear speckles) domains. TCGA analysis was performed for prognostic assessment and correlation analysis of RanBP17 in HNSCC patients.

Results

RNAi knockdown of RanBP17, significantly reduced cell proliferation in HNSCC cell lines. This effect was also seen in the HNSCC unrelated cell lines HCT116 and MDA-MB-231. Similarly, inhibiting cell proliferation with cisplatin reduced RanBP17 in keratinocytes but lead to induction in tumor cell lines. A similar observation was made in tumor cell lines after treatment with the EGFR kinase inhibitor AG1478. In addition to previous reports, showing colocalization of RanBP17 with SC35 domains, we observed colocalization of RanBP17 to nuclear bodies that are distinct from nucleoli and SC35 domains. Interestingly, for HPV positive but not HPV negative HNSCC, TCGA data base analysis revealed a strong positive correlation of RanBP17 RNA with patient survival and CDKN2A.

Conclusions

Our data point to a role of RanBP17 in proliferation of HNSCC and other epithelial cells. Furthermore, RanBP17 could potentially serve as a novel prognostic marker for HNSCC patients. However, we noted a major discrepancy between RanBP17 RNA and protein expression levels with the used antibodies. These observations could be explained by the presence of additional RanBP17 splice isoforms and more so of non-coding circular RanBP17 RNA species. These aspects need to be addressed in more detail by future studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09854-0.

[Pre-treatment dysphagia in head-and-neck cancer patients]

BACKGROUND

The swallowing and nutritional status of head-and-neck cancer patients after oncological therapy have been extensively researched. However, the same topics are seldom scrutinized before the onset of oncological therapy, although they can influence treatment success in the long term.

OBJECTIVE

This study focusses on a systematic assessment of swallowing function and nutritional status in head-and-neck cancer patients prior to oncological therapy.

MATERIALS AND METHODS

In 102 patients, penetration/aspiration (PA scale), limitations of oral intake (Functional Oral Intake Scale, FOIS), and the need for further intervention (NFI) were endoscopically assessed to objectively quantify swallowing function. The subjective evaluation of swallowing function was carried out with the gEAT-10 (German EAT-10) questionnaire, nutritional status was assessed by body mass index (BMI). Possible impact factors for swallowing function and BMI were analyzed by univariate and multivariate methods.

RESULTS

PAS, FOIS, and NFI values were abnormal in ≤ 15% of patients. BMI was more often too high than too low. Objectively assessed swallowing functions depended predominantly on tumor stage and showed moderate correlations with gEAT-10. The latter mostly yielded a "fail" result. The nutritional status depended on the patients' biological sex and NFI.

CONCLUSION

In the pre-treatment setting, neither dysphagia nor malnutrition were found in most patients. Impaired swallowing was associated with higher tumor stages, malnutrition with female sex and NFI. A systematic pre-treatment assessment of swallowing and nutritional status in head-and-neck cancer patients appears necessary for modern oncological therapy and optimal patient outcome.

[Interdisciplinary management of extracranial vascular anomalies]

BACKGROUND

A multitude of vascular anomalies exist and can lead to severe complications. Treatment can be complex.

OBJECTIVE

This overview aims to provide important information for the management of vascular anomalies.

MATERIALS AND METHODS

In addition to current literature, experiences from the interdisciplinary Vascular Anomalies Center in Marburg were included in this review.

RESULTS

Hemangiomas at critical sites, arteriovenous malformations, and vascular anomalies of uncertain etiology require particular attention.

CONCLUSION

Self-help and support groups, specialized interdisciplinary centers, scientific medical societies, and networks can provide help for the treatment of vascular anomalies.

UV-C Light-Based Surface Disinfection: Analysis of Its Virucidal Efficacy Using a Bacteriophage Model

Background: The reprocessing of medical devices has become more complex due to increasing hygiene requirements. Previous studies showed satisfactory bactericidal disinfection effects of UV-C light in rigid and flexible endoscopes. Especially in the context of the current COVID-19 pandemic, virucidal properties are of high importance. In the present study, the virucidal efficacy of UV-C light surface disinfection was analyzed. Methods: MS-2 bacteriophages were applied to the test samples and irradiated by UV-C light using the UV Smart D25 device; unirradiated test samples were used as controls. A dilution series of the samples was mixed with 1 × 108 Escherichia coli and assayed. Results: 8.6 × 1012 pfu could be harvested from the unprocessed test samples. In the control group without UV-C exposure, a remaining contamination of 1.2 × 1012 pfu was detected, resulting in a procedural baseline reduction rate with a LOG10 reduction factor of 0.72. The LOG10 reduction factor was found to be 3.0 after 25 s of UV-C light exposure. After 50 and 75 s of UV-C radiation LOG10 reduction factors 4.2 and 5.9, respectively, were found, with all reductions being statistically significantly different to baseline. Conclusions: The tested UV system seems to provide a significant virucidal effect after a relatively short irradiation time.

Carbon Ion Beam Boost Irradiation in Malignant Tumors of the Nasal Vestibule and the Anterior Nasal Cavity as an Organ-Preserving Therapy

Background

Surgery and radiotherapy are current therapeutic options for malignant tumors involving the nasal vestibule. Depending on the location, organ-preserving resection is not always possible, even for small tumors. Definitive radiotherapy is an alternative as an organ-preserving procedure. Carbon ion beam radiotherapy offers highly conformal dose distributions and more complex biological radiation effects eventually resulting in optimized normal tissue sparing and improved outcome. The aim of the current study was to analyze toxicity, local control (LC), and organ preserving survival (OPS) after irradiation of carcinoma of the nasal vestibule with raster-scanned carbon ion radiotherapy boost (CIRT-B) combined with volumetric intensity modulated arc therapy (VMAT) with photons.

Methods

Between 12/2015 and 05/2021, 21 patients with malignant tumors involving the nasal vestibule were irradiated with CIRT-B combined with VMAT and retrospectively analyzed. Diagnosis was based on histologic findings. A total of 17 patients had squamous cell carcinoma (SCC) and 4 had other histologies. In this series, 10%, 67%, and 24% of patients had Wang stages 1, 2, and 3 tumors, respectively. Three patients had pathologic cervical nodes on MRI. The median CIRT-B dose was 24 Gy(RBE), while the median VMAT dose was 50 Gy. All patients with pathologic cervical nodes received simultaneously integrated boost with photons (SIB) up to a median dose of 62.5 Gy to the pathological lymph nodes. Eight patients received cisplatin chemotherapy. All patients received regular follow-up imaging after irradiation. Kaplan–Meier estimation was used for statistical assessment.

Results

The median follow-up after irradiation was 18.9 months. There were no common toxicity criteria grade 5 or 4 adverse events. A total of 20 patients showed grade 3 adverse events mainly on skin and mucosa. All patients were alive at the end of follow-up. The median OPS after treatment was 56.5 months. The 6- and 24-month OPS were 100% and 83.3%, respectively. All local recurrences occurred within 12 months after radiotherapy. The median progression free survival (PFS) after treatment was 52.4 months. The 6-, 12-, and 24-month PFS rates were 95%, 83.6%, and 74.3%, respectively.

Conclusion

CIRT-B combined with VMAT in malignant tumors of the nasal vestibule is safe and feasible, results in high local control rates, and thus is a good option as organ-preserving therapy. No radiation-associated grade 4 or 5 acute or late AE was documented.

Hypoglossal nerve stimulation for obstructive sleep apnea: updated position paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery

Since the first statement of the German Society of Oto-Rhino-Laryngology, hypoglossal nerve stimulation (HNS) is meanwhile an established treatment option for obstructive sleep apnea (OSA). There are three HNS systems available in Germany which differ in their technical details of the underlying comparable basic principle. For the unilateral HNS with respiratory sensing, several comparative studies, high-volume register analysis and long-term reports exist. The continuous HNS without respiratory sensing does not require a sleep endoscopy for indication. For the bilateral continuous HNS as the single partially implantable device, a feasibility study exists. For indication, the assessment of positive airway pressure failure by sleep medicine is crucial, and the decision for HNS should be made in discussion of other treatment options for at least moderate OSA. The implantation center holds primarily responsibility among the interdisciplinary sleep team and is primary contact for the patient in problems. This depicts why structural processes are required to secure outcome quality and minimize the complications. The aftercare of HNS patients can be provided interdisciplinary and by different medical institutions, whereat, minimal reporting standards to document outcome and usage are recommended.

Clinical Impact of CYFRA 21-1 a Marker for Treatment Failure in Patients With Oropharyngeal Cancer Treated by Radio(chemo)therapy

BACKGROUND

Primary radio(chemo)therapy [R(C)T] is a treatment option for advanced oropharyngeal squamous cell carcinoma (OSCC). Nevertheless, early diagnostics of treatment failure is problematic. Cytokeratin fragment 19 (CYFRA 21-1), an established marker in the management of pulmonary cancer, might be helpful here. Hence, in this study the impact of CYFRA 21-1 as an indicator for treatment failure and tumor recurrence (TR) in OSCC after R(C)T was analyzed.

PATIENTS AND METHODS

The data of 77 patients with advanced OSCC and R(C)T were retrospectively examined. For determination of CYFRA 21-1 at the time of diagnosis and after R(C)T, an electrochemiluminescence immunoassay was used. Tumor residuals and tumor recurrence were pathologically verified after detection by radiological imaging and endoscopy. The mean follow-up was 44.4 months.

RESULTS

After R(C)T, 48 (62%) patients showed locoregional control and 29 (38%) patients experienced locoregional failure. No statistical difference in the CYFRA 21-1 level between groups both before (p=0.75) and after R(C)T (p=0.85) was found. Nevertheless, in cases of TR in follow-up, the CYFRA 21-1 level was significantly higher (p≤0.01). The occurrence of TR was significantly associated with a CYFRA 21-1 elevation at this time (p≤0.01). However, CYFRA 21-1 failed to show a suitable discriminative ability for TR (area under the curve=0.57).

CONCLUSION

In OSCC, CYFRA 21-1 does not seem to be a useful marker for locoregional failure after R(C)T. Nevertheless, a higher level immediately after R(C)T and in the further course of the disease may be associated with TR in individual patients.

Sleep position, patient comfort, and technical performance with two established procedures for home sleep testing

Purpose

In patients with a high pre-test probability of suffering from obstructive sleep apnea (OSA), (cardio)-respiratory polygraphy (RP; level 3) is commonly used for home sleep testing (HST); however, testing based on peripheral arterial tonometry (PAT) is increasingly recognized as an alternative method. The aim of the study was to compare sleep position, patients’ comfort, and technical failure rates of HST with RP and PAT in patients with suspected OSA.

Methods

Sleep position, patients’ comfort, and technical failure rates of RP and PAT were compared in 56 patients receiving two nights of HST with either RP or PAT in a randomized fashion.

Results

Time in supine position with PAT was significantly lower (173.7±88 min) compared to RP (181.7±103.7 min; p < 0.001), although the absolute mean difference was not clinically significant. Patients reported to sleep better, feeling less disturbed when falling asleep, losing less sensors, and fewer nightly awakenings with PAT, but experienced more pain at the side of the finger probe. Forty-five out of 56 patients (80%) rated PAT as being the superior sleep test and 49 out of 56 (88%) would prefer PAT for further investigations (p<0.001). PAT testing was associated with less technical failures.

Conclusion

The results demonstrate that HST with PAT leads to less time in supine sleep positioning, which may be clinically relevant in selected patients. Moreover, PAT is associated with less technical failures and is perceived with less discomfort during testing and a reduced number of nocturnal awakenings in patient self-reports.

[Epistaxis-overview and current aspects]

Nosebleeds (epistaxis) are usually minor. Medical intervention is only necessary in about 6% of cases. The source of bleeding is frequently located in the anterior region of the nose (Kiesselbach's plexus). The estimated lifetime prevalence of epistaxis is 60%. Diffuse epistaxis is often a manifestation of systemic disease. Epistaxis is the leading symptom of Rendu-Osler-Weber disease (hereditary hemorrhagic telangiectasia, HHT). If intervention is required, the first-choice of treatment is bidigital compression for several minutes. Common therapeutic measures include local hemostasis using electrocoagulation or chemical agents, e.g., silver nitrate. Resorbable anterior nasal tampons or tampons with a smooth surface are also frequently employed. In case of failed surgical closure of the sphenopalatine artery, angiographic embolization is the method of choice.

Post-operative hearing among patients with labyrinthine fistula as a complication of cholesteatoma using "under water technique"

Introduction

During surgery in patients with labyrinthine fistula the mandatory complete removal of the cholesteatoma while preserving inner ear and vestibular function is a challenge. Options so far have been either the complete removal of the cholesteatoma or leaving the matrix on the fistula. We evaluated an alternative “under water” surgical technique for complete cholesteatoma resection, in terms of preservation of postoperative inner ear and vestibular function.

Methods

From 2013 to 2019, 20 patients with labyrinthine fistula due to cholesteatoma were operated. We used the canal wall down approach and removal of matrix on the fistula was done as the last step during surgery using the “under water technique”. The pre and postoperative hearing tests and the vestibular function were retrospectively examined.

Results

There was no significant difference between pre and post-operative bone conduction thresholds; 20% experienced an improvement of more than 10 dB, with none experiencing a postoperative worsening of sensorineural hearing loss. Among seven patients who presented with vertigo, two had transient vertigo postoperatively but eventually recovered.

Conclusion

Our data show that the “under water technique” for cholesteatoma removal at the labyrinthine fistula is a viable option in the preservation of inner ear function and facilitating complete cholesteatoma removal.

On the impairment of executive control of attention in chronic tinnitus: Evidence from the attention network test

Subjective, chronic tinnitus is a condition that is common in most populations. Whereas many individuals tend to habituate to tinnitus over time, for some their attention seems pathologically drawn towards the sensation. For this subgroup of individuals with severe tinnitus, dysfunctional executive attention has been suggested to be implicated in the failure to habituate. However, since most previous studies have used attention tests with low validity and specificity in this assessment, there is a need for further corroborating studies. In the present study, the Attention Network Test was used to compare mainly the efficiency of executive attention between a group of individuals with chronic tinnitus (TG; n = 33) and a healthy control group (CG; n = 37). The results showed that individuals with chronic tinnitus, compared to the CG, did not present with a specific impairment in executive control of attention, nor in any of the other two attention domains. These findings are discussed in relation to the sampling characteristics in this study, which might have led to the sample being more homogenous and high functioning than samples in tinnitus studies generally. Overall, this study suggests that tinnitus and executive control of attention impairment might not be directly related, and that the latter might not necessarily be associated with the maintenance of the condition.

[Post-operative prevalence of dysphagia in head-and-neck cancer patients in the acute care units]

OBJECTIVE

 Dysphagia constitutes a frequent post-operative functional impairment in head-and-neck cancer patients. This impairment can result in aspiration/penetration and limitations of oral intake. Therefore, often it requires a therapeutic intervention. In this study, prevalence of post-operative dysphagia and its associations with the tumour stage, localisation, patients' age, and biological sex were analysed for the inpatient treatment setting.

MATERIAL AND METHODS

 A total of 201 adult head-and-neck cancer patients (mean age 63 years) were analysed prospectively by FEES in two university hospitals in regard to their penetration/aspiration, limitations of oral intake, and need for therapeutic interventions directly after the operative tumour treatment. Additionally, the influence of the same patients' characteristics on these three parameters were analysed by means of univariate and multivariate statistical methods.

RESULTS

 Out of 201 patients, 66.7 % needed a therapeutic intervention because of their dysphagia, 57.2 % needed a nasogastral or PEG tube due to limitations of oral intake, 45.3 % had an aspiration. In the latter subgroup, 38.5 % had a silent aspiration. Higher tumour stage, patients' higher age and male sex were shown to be significant influence factors for dysphagia, tumour localisation showed only a marginally significant result.

CONCLUSIONS

 The study demonstrated a clinical importance and relevance of the consequent and systematic treatment of post-operative dysphagia in head-and-neck cancer patients in the acute care units as a constituent of a modern oncological therapy.

Cocaine Reduces Ciliary Beat Frequency of Human Nasal Epithelial Cells

BACKGROUND/AIM

Cocaine is a widely used recreational drug and is known for its nasal complications including epithelial, cartilage and bone damage. The aim of the study was to analyze the impact of cocaine on ciliary beat frequency (CBF) of human nasal epithelial cells and therefore better understand its side effects on nasal mucosa.

MATERIALS AND METHODS

Nasal epithelial cells of 21 healthy subjects were harvested and exposed in vitro to cocaine hydrochloride solutions ranging from 0.875% to 7%. High-speed video footage was acquired with phase contrast microscopy and CBF was analyzed with Sissons-Ammons Video Analysis (SAVA) software.

RESULTS

All tested concentrations led to a significant reduction in CBF compared to the control. Effects increased over time and with concentration. A mechanical inhibition of cilia by cocaine crystals was also observed.

CONCLUSION

We assume that CBF reduction is part of the pathomechanism leading to nasal complications in cocaine abuse. Considering these results, clinical usage of cocaine should be critically evaluated and restricted to select cases only.

Treatment of juvenile recurrent parotitis with irrigation therapy without anesthesia

Purpose

No standardized treatment regimen exists for juvenile recurrent parotitis (JRP). The investigators hypothesized that irrigation with saline only without local anesthesia will be an effective and beneficial option.

Methods

Using a retrospective study design, a series of children with typical symptoms of JRP who were treated with at least one irrigation therapy were evaluated. This treatment consisted of irrigation of the affected gland with 3–10 ml saline solution without any type of anesthesia. The outcome variables were patient/parent satisfaction, frequency and duration of acute JRP episodes, and the need for antibiotics before and after irrigation therapy.

Results

The case series was composed of six boys aged 3.3–7.7 years who experienced one to eight sessions of irrigation therapy. The period of follow-up was 9–64 months. We observed a total resolution of symptoms in two children and an improvement in the other four. No relevant side effects were seen.

Conclusion

Our results suggest that irrigation therapy is a reasonable, simple, and minimally invasive treatment alternative for JRP. In contrast to sialendoscopy or sialography, there is no need for general anesthesia or radiation exposure.

UV light-based reprocessing of flexible endoscopes without working channel in Oto-Rhino-Laryngology: an effective method?

Background

Reprocessing of flexible endoscopes (FEs) is often expensive, time consuming, and becomes increasingly complex, due to rising demands of hygiene. After beneficial results in reprocessing of rigid endoscopes using Impelux™ UV-C light technology, we tested the same method for reprocessing of FEs without working channel.

Materials and methods

Testing was performed on FEs without working channel after routine clinical use (transnasal flexible endoscopy). Disinfection consisted of mechanical precleaning and 60 s exposure to Impelux™ UV-C light technology. Bacterial contamination was tested on 50 FEs before and after disinfection. Further 50 FEs regarding protein residuals. The absolute effectiveness of the D60 was tested on 50 test bodies (RAMS) with a standardized contamination of 10⁷ colony-forming units (CFU) of Enterococcus faecium.

Results

The FEs were contaminated with a high average value of 916.7 CFU (± 1057 CFU) after clinical usage. After reprocessing, an average contamination of 2.8 CFU (± 1.6) on 14% (n = 7) of the FEs was detected consisting of non-pathogenic species, the remaining FE were sterile. After reprocessing, all FEs were protein-free (< 1 μg). The artificially contaminated test bodies showed no remaining bacterial contamination after disinfection, resulting in an average absolute germ reduction of about 10⁷ CFU.

Conclusion

Impelux™ UV-C light technology efficiently reduces bacterial contamination of FEs and might be useful in daily practice.

[Perioperative medical prophylaxis of venous thromboembolic events in head and neck surgery : A retrospective study and recommendations]

BACKGROUND

In the authors' department, a newly implemented clinical algorithm for application of perioperative thrombosis prophylaxis in head and neck surgery recommends restrictive handling of anticoagulants. This retrospective study aims to evaluate the algorithm by comparing incidences of venous thromboembolic events (VTE) and surgical revisions due to postoperative hemorrhage.

MATERIALS AND METHODS

Perioperative incidences of deep vein thrombosis and pulmonary embolism as well as surgical revisions due to postoperative hemorrhage after head and neck surgery were determined based on all patients operated in the department over a period of 36 months. The incidences before (group I) and after (group II) implementation of the restrictive algorithm were compared.

RESULTS

A total of 9276 patients were included. The incidences of VTE (0.12%) and surgical revisions due to postoperative hemorrhage (1.4%) were low. Incidences of VTE were non-significantly higher in group II (0.16%) than in group I (0.08%; p > 0.45, chi-square-test). Case analysis revealed that this difference was not due to implementation of the restrictive algorithm. The incidence of surgical revision due to postoperative hemorrhage was identical in the two groups (1.4%).

CONCLUSION

After restricting the indication for thrombosis prophylaxis, the incidence of VTE or surgical revision due to postoperative hemorrhage did not change significantly. The provided clinical algorithm represents a low-risk and low-cost strategy of perioperative risk stratification.

[Differential diagnosis of hypersomnia in surgical sleep medicine-more than just sleep apnea!]

Otorhinolaryngologists play a vital role in the management of patients with obstructive sleep apnea (OSA) in Germany, particularly with regards to outpatient diagnostics as well as conservative and surgical treatment of patients with intolerance to ventilation therapy. Although establishment of differential indications for surgical therapy and performance of additional preoperative drug-induced sleep endoscopy in patients with sleep-disordered breathing are among the core competencies of otorhinolaryngologists, differential diagnostic considerations and detection of comorbid sleep disorders can be challenging, particularly for those without extensive sleep medicine training and experience. However, detection of comorbid sleep disorders is of particular importance when permanent surgical treatment is considered. Daytime sleepiness is the typical leading symptom of OSA; nevertheless, other disorders of hypersomnolence need to be considered in these patients and can easily be overlooked. This may lead to inadequate indications for surgical treatment. Based on two case reports, narcolepsy is presented as a comorbid disorder and differential diagnosis in patients with OSA.

[Effects of the SARS-CoV‑2 pandemic on the otolaryngology university hospitals in the field of research, student teaching and specialist training]

Hintergrund

Ab Frühjahr 2020 kam es zur weltweiten Verbreitung von SARS-CoV‑2 mit der heute als erste Welle der Pandemie bezeichneten Phase ab März 2020. Diese resultierte an vielen Kliniken in Umstrukturierungen und Ressourcenverschiebungen. Ziel unserer Arbeit war die Erfassung der Auswirkungen der Pandemie auf die universitäre Hals-Nasen-Ohren(HNO)-Heilkunde für die Forschung, Lehre und Weiterbildung.

Material und Methoden

Die Direktorinnen und Direktoren der 39 Universitäts-HNO-Kliniken in Deutschland wurden mithilfe einer strukturierten Online-Befragung zu den Auswirkungen der Pandemie im Zeitraum von März bis April 2020 auf die Forschung, Lehre und die Weiterbildung befragt.

Ergebnisse

Alle 39 Direktorinnen und Direktoren beteiligten sich an der Umfrage. Hiervon gaben 74,4 % (29/39) an, dass es zu einer Verschlechterung ihrer Forschungstätigkeit infolge der Pandemie gekommen sei. Von 61,5 % (24/39) wurde berichtet, dass pandemiebezogene Forschungsaspekte aufgegriffen wurden. Von allen Kliniken wurde eine Einschränkung der Präsenzlehre berichtet und 97,5 % (38/39) führten neue digitale Lehrformate ein. Im Beobachtungszeitraum sahen 74,4 % der Klinikdirektoren die Weiterbildung der Assistenten nicht gefährdet.

Schlussfolgerung

Die Ergebnisse geben einen Einblick in die heterogenen Auswirkungen der Pandemie. Die kurzfristige Bearbeitung pandemiebezogener Forschungsthemen und die Einführung innovativer digitaler Konzepte für die studentische Lehre belegt eindrücklich das große innovative Potenzial und die schnelle Reaktionsfähigkeit der HNO-Universitätskliniken, um auch während der Pandemie ihre Aufgaben in der Forschung, Lehre und Weiterbildung bestmöglich zu erfüllen.

[German S1 guideline: obstructive sleep apnea in the context of tonsil surgery with or without adenoidectomy in children-perioperative management]

Otolaryngologic surgery is one of the most frequent operative interventions performed in children. Tonsil surgery with or without adenoidectomy due to hyperplasia of the tonsils and adenoids with obstruction of the upper airways with or without tympanic ventilation disorder is the most common of these procedures. Children with a history of sleep apnoea (OSA) suffer from a significantly increased risk of perioperative respiratory complications. Cases of death and severe permanent neurologic damage have been reported due to apnoea and increased opioid sensitivity. The current guideline represents a pragmatic risk-adjusted approach. Patients with confirmed or suspected OSA should be treated perioperatively according to their individual risks and requirements, in order to avoid severe permanent damage.

Changes in Vestibular Function in Patients With Head-and-Neck Cancer Undergoing Chemoradiation

INTRODUCTION

While the cochleotoxicity of cisplatin has been well investigated, less is known about the effects of platinum-based chemotherapy on the vestibular system. In particular, there is a lack of prospective studies using modern laboratory vestibular testing that examine the effects of cisplatin on the semicircular canals and on the otolith organs. The aim of the present study was, therefore, to investigate the vestibulotoxic effect of cisplatin in patients with head and neck tumors who are undergoing chemoradiation.

METHODS

Forty-five patients undergoing cisplatin-based chemoradiation for head and neck cancer received a vestibular assessment consisting of anamnesis, a horizontal video head impulse test (vHIT), ocular and cervical vestibular evoked myogenic potential testing, as well as pure tone audiometry. This assessment was performed before therapy, 6 weeks after therapy, and 3 months after therapy.

RESULTS

Video head impulse test showed a significantly reduced median gain 6 weeks after chemoradiation. In addition, significantly more refixational saccades could be detected after therapy. Vestibular evoked myogenic potential testing results also revealed significant changes, whereas pure tone audiometry did not. None of the patients mentioned "dizziness" during the follow-up examinations.

CONCLUSION

We demonstrated a vestibulotoxic effect of cisplatin-based chemoradiation in patients with head and neck cancer. Future studies are needed to better understand cisplatin-induced vestibulotoxicity and to identify possible vestibuloprotective substances. Still, before and after chemoradiation, patients should undergo not only auditory testing but also vestibular testing in order to detect potential vestibular loss as soon as possible and to quickly initiate vestibular physiotherapy.

[Effects of the SARS-CoV-2 pandemic on the otorhinolaryngology university hospitals in the field of medical care]

INTRODUCTION

Since December 2019, the SARS-CoV-2 virus has been rapidly spreading worldwide. In Germany, an exponential increase in the number of infections was registered at the beginning of March 2020 and led to a call of the Ministry of Health to create more capacity for intensive medical treatment in hospitals. The aim of the present study was to determine the effects of the SARS-CoV-2 pandemic on Oto-Rhino-Laryngology (ORL) university hospitals regarding patient care.

MATERIALS AND METHODS

An online survey was sent out to all chairmen of the 39 ORL university hospitals in Germany. The answers to the questions referred to the defined period from March 15^th to April 15^th 2020 and were carried out using the online survey tool "SurveyMonkey". 87 questions focused on general information, health care, and structural effects in the respective institution.

RESULTS

All chairmen of the 39 university hospitals in Germany participated in the survey. The collected data prove the considerable impact on organizational, structural and medical aspects of patient care. For example, the surveyed clinics reported a decrease in outpatient cases by 73.8 % to 26.2 ± 14.2 % and in surgical treatments by 65.9 % to 34.1 ± 13.9 %. In contrast, emergency treatment remained unchanged or even increased in 80 % of the facilities and surgical treatment of emergency patients remained unchanged or even increased in more than 90 %. Emergency outpatient and surgical treatment of patients was provided throughout the pandemic in all facilities. In total, about 35 000 outpatients and about 12 000 surgical cases were postponed. As a result of the acute structural changes, the potential danger of falling below current treatment standards was seen in individual areas of patient care.

DISCUSSION

The assessment of the impact of the SARS-CoV-2 pandemic is heterogeneous. The majority of the chairmen are critically aware of the risk of falling below current medical treatment standards or guidelines. In the phase of an exponential increase in the number of infections, significant changes in treatment processes had to be accepted for understandable reasons. However, with the currently significantly reduced number of infections, falling below treatment standards and guidelines should not be allowed to remain constant and tolerated.

SUMMARY

This study shows a differentiated picture with regard to the effects of the SARS-CoV-2 pandemic on outpatient, inpatient and operative patient care at the ORL university hospitals in Germany and illustrates the importance of these institutions for ensuring patient care during this critical phase.

Diagnosis and treatment of isolated snoring-open questions and areas for future research

STUDY OBJECTIVES

Snoring is a common phenomenon which is generated by vibration of soft tissue of the upper airway during sleep. Due to the high incidence of isolated snoring and the substantial burden for the patient and the bed partner, a thorough examination and appropriate therapy are required. Many recommendations for the treatment of isolated snoring are either not evidence-based or are derived from recommendations for the management of obstructive sleep apnea. Therefore, the aim of this study is the identification and description of open questions in the diagnosis and treatment of isolated snoring and the illustration of areas for further research.

METHODS

In the context of the development of the new version of the German guideline "Diagnosis and treatment of isolated snoring in adults," a multidisciplinary team of experts performed a systematic literature search on the relevant medical data and rated the current evidence regarding the key diagnostic and therapeutic measures for snoring.

RESULTS

The systematic literature review identified 2293 articles. As a major inclusion criterion, only studies on primary snoring based on objective sleep medical assessment were selected. After screening and evaluation, 33 full-text articles remained for further analysis. Based on these articles, open questions and areas for future research were identified for this review.

CONCLUSION

Several major gaps in the literature on the diagnosis and treatment of isolated snoring were identified. For the majority of diagnostic and therapeutic measures for snoring, high-level scientific evidence is still lacking.

Aberrant Expression of Glyceraldehyde-3-Phosphate Dehydrogenase (GAPDH) in Warthin Tumors

The Warthin tumor represents the second most frequent benign tumor of the parotid gland and is characterized by the presence of oncocytes rich in structurally and functionally altered mitochondria. Next to its role in metabolism, glyceraldehyde-3-phosphate dehydrogenase (GAPDH) is also implicated in cellular mitophagy. Immunohistochemistry was carried out on Warthin tumor and normal control (parotid gland with striated ducts) tissues, using anti-GAPDH specific antibodies followed by digital image analysis. Laser capture microdissection was used to isolate the oncocytic tumor cell and normal control striated duct compartments for RNA extraction and qPCR. Warthin tumor oncocytes exhibited a markedly spotted GAPDH staining pattern exhibiting cells with cytoplasmic and nuclear, only nuclear or none GAPDH staining. A significantly lower (p < 0.0001) total GAPDH signal was detected in Warthin tumor oncocytes. Similarly, significantly lower (p < 0.005) GAPDH mRNA levels were seen in oncocytes compared with normal ductal cells. To exclude the possibility of this GAPDH staining pattern being a general feature of oncocytic neoplasms of different organs, we tested a cohort of renal oncocytoma and oncocytic chromophobe carcinoma; none showed this type of staining. The observed progressive GAPDH loss in Warthin tumor oncocytes could be implicated in the pathogenesis of Warthin tumors.

Nightly Hypoxia Does Not Seem to Lead to Otolith Dysfunction in Patients With Obstructive Sleep Apnea

OBJECTIVES

Obstructive sleep apnea (OSA) is a common sleep disorder, which is associated with recurrent oxygen desaturation during sleep. It has already been shown that nocturnal hypoxia may lead to cochlear dysfunction in patients with OSA. Less is known whether hypoxia during sleep also impacts vestibular function in those patients. Thus, the aim of the presented study was to assess a potential vestibulotoxic effect of nightly desaturations with hypoxia in patients with OSA by investigating a possible correlation between respiratory parameters and vestibular function tests.

METHODS

A total of 56 patients were included in the study and underwent a fully attended cardiorespiratory polysomnography (PSG). Vestibular function was assessed using video head impulse test to evaluate horizontal semicircular canal function and cervical vestibular evoked myogenic potentials (cVEMPs) and ocular vestibular evoked myogenic potentials (oVEMPs) to measure otolith function. Descriptive data analysis was conducted and correlation analysis between selected PSG parameters and the results of vestibular testing was performed using Kendall τ coefficient.

RESULTS

A significant correlation between vestibular function and respiratory polysomnographic parameters could not be demonstrated in the study (P > .05) but cVEMP and oVEMP results showed a trend toward a correlation with oxygen desaturation indices and apnea-hypopnea index. Additionally, otolith hypofunction was more prevalent in patients with hypertension as well as OSA.

CONCLUSION

The results of our study show that there is no significant correlation between vestibular function and sleep apnea parameters, although otolith dysfunction might be more prevalent in patients with OSA and hypertension.

Plasma cells, plasmablasts, and AID+/CD30+ B lymphoblasts inside and outside germinal centres: details of the basal light zone and the outer zone in human palatine tonsils

Plasma cells (PCs) in human palatine tonsils are predominantly located in the germinal centres (GCs), in the subepithelial space and near the deep connective tissue septa surrounding each crypt. We analysed the location, phenotype, and proliferation of GC PCs by immunohistology comparing them to PCs in the other two locations. Most PCs in GCs were strongly positive for CD38, CD138, CD27, IRF4, and intracellular (ic) IgG. They often accumulated in the basal light zone, but could also be found scattered in the entire light zone. In addition, rows of PCs occurred at the surface of the GC bordering the mantle zone, i.e., in the outer zone, and at the surface of the dark zone. The latter cells were often continuous with PCs in the extrafollicular area. The vast majority of GC PCs were negative for Ki-67. Only a few Ki-67⁺ plasmablasts, predominantly icIgG⁺ or icIgM⁺, were found inside GCs. In certain GCs PCs accumulated around capillaries and the adjacent perikarya of follicular dendritic cells (FDCs). Newly formed PCs might migrate from the basal to the superficial part of the light zone and then back to the dark zone surface to leave the GC. This guarantees an even distribution of secreted Ig for exchange with immune complexes on FDCs. The surface of the dark zone may also be an exit site for Ki-67⁺CD30⁺ B lymphoblasts, which seed perifollicular and extrafollicular sites. We speculate that these cells tend to downmodulate CD20 and activation-induced deaminase and further up-regulate CD30 when developing into pre-plasmablasts.

Wenn CPAP nicht genutzt oder nicht vertragen wird – Vorschlag für eine standardisierte Terminologie

Hintergrund

Die Standardtherapie einer obstruktiven Schlafapnoe (OSA) ist die nächtliche positive Überdruckbeatmung (PAP). Sie ist in der Regel nebenwirkungsarm und stellt eine Langzeittherapie dar. Doch nicht jeder Patient toleriert oder akzeptiert die Therapie oder möchte sie fortführen. Andere müssen sie aus objektiven Gründen beenden.

Fragestellung

Klare Begrifflichkeiten für eine Nicht-Anwendung der PAP-Therapie sind bisher nicht in den Leitlinien definiert. Ziel dieses Beitrags ist es, einheitliche Definitionen einzuführen, die eine Vorlage für klinisches Handeln und wissenschaftliche Ansätze sein können.

Material und Methode

Ein Expertengremium hat sich intensiv mit der Literatur, Definitionen und Hintergrundinformationen hinsichtlich des Themas befasst. Es wurden verschiedene Möglichkeiten der PAP-Nicht-Nutzung bzw. der Beendigung der Therapie betrachtet und dementsprechend Kategorien und Definitionen zusammengestellt.

Ergebnisse

Dies sind die vom Expertengremium vorgeschlagenen Kategorien für eine PAP-Nichtbenutzung: PAP-Inakzeptanz, PAP-Unverträglichkeit, PAP-Intoleranz, PAP-Versagen und PAP-Abbruch.

Diskussion

Diese Kategorien inklusive Definition können die Grundlage für ein einheitliches Management bei Patienten/Patientinnen mit obstruktiver Schlafapnoe (OSA) sein, die auf eine PAP-Therapie eingestellt werden bzw. wurden.

The Diagnosis and Treatment of Snoring in Adults

BACKGROUND

Snoring in adults is a common cause of distress for patients and their bedpartners and calls for appropriate counseling, diagnostic evaluation, and treatment.

METHODS

A systematic literature search in the PubMed, Cochrane Library, Web of Science Core Collection, and ClinicalTrials.gov databases was carried out in February 2018 and yielded pertinent publications from 2000 onward. The guideline was created according to the methodological requirements of the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der wissenschaft- lichen medizinischen Fachgesellschaften, AWMF).

RESULTS

The diagnostic evaluation of snoring is based on the history and phyical examination. In certain situations, a specialized sleep study should be performed to obtain objec- tive findings. The recommended methods of conservative treatment include, in particular, positioning therapy and weight loss. Mandibular protrusion splints can lessen snoring in suitable cases. If breathing through the nose is impaired, rhinological or rhinosurgical treatment is recommended; for certain anatomical abnormalities of the soft palate, a suitable minimally invasive surgical procedure can be considered. The level of the available evidence is low, as most of the under- lying clinical studies involved small patient groups and short follow-up.

CONCLUSION

In the treatment of snoring, evidence-based recommendations derived from the findings of randomized trials can be given for selected situations, yet the overall state of the evidence on many diagnostic and therapeutic tech- niques remains limited.

CYFRA 21-1: a suitable tumor marker in patients with head and neck cutaneous squamous cell carcinoma?

PURPOSE

The clinical significance of cytokeratin fraction 21-1 (CYFRA 21-1) for patients with head and neck cutaneous squamous cell carcinoma (CSCC) is unknown. Thus, the aim of the study was to evaluate the clinical value of CYFRA 21-1 in the context of treatment and follow-up for these patients.

METHODS

The clinical, histological and laboratory data of a total of 55 patients with the first diagnosis of head and neck cutaneous squamous cell carcinoma (T1-T4, N0-N2b, M0-1) between 2003 and 2017 were retrospectively analyzed. In 25 cases, the primary tumor could be treated successfully without residual or recurrent disease in the further course. The average follow-up period was 2.3 years. In all patients, pretherapeutic determination of CYFRA 21-1 was performed using the ECLIA test kit. The cut-off value was set at 3.3 ng/ml.

RESULTS

In 18 patients (32.7%), regional recurrence was found in the course of treatment. Distant metastases could be observed in two patients (3.6%). In these cases, no significant increase of CYFRA 21-1 blood concentration was detected at the time of recurrence/metastasis. At the time of the first diagnosis, the mean value of CYFRA 21-1 blood concentration was 2.4 ng/ml; and in cases of regional recurrence or distant metastases, the initial mean CYFRA 21-1 concentration was 2.0 ng/ml. There was no statistically significant relationship between CYFRA 21-1 blood concentration and analyzed tumor characteristics.

CONCLUSIONS

According to current knowledge, the tumor marker CYFRA 21-1 is not clinically significant for treatment and follow-up of patients with head and neck CSCC.

Nasal self-packing for epistaxis in Hereditary Hemorrhagic Telangiectasia increases quality of life

STATEMENT OF PROBLEM

Hereditary hemorrhagic telangiectasia (HHT) is characterized by recurrent epistaxis that can lead to a feeling of losing control. We assessed potential benefits and side effects of different nasal packings used by patients themselves.

METHOD OF STUDY

An online-questionnaire in English and German was used to analyze nasal self-packings.

RESULTS

588 of the 915 respondents suffered from HHT with most of them having moderate or severe epistaxis. Almost two thirds of the patients had already treated themselves with nasal packings. While one quarter used non-pneumatic nasal packings (NPNP) or pneumatic nasal packings (PNP), nearly half of the patients took only tissues to stop the bleeding. Patients with severe epistaxis used PNP more often than NPNP. Using nasal packings, most patients could stop their nosebleeds after a while. Patients using PNP reported the feeling of losing control less often and significant improvements in quality of life with a positive GBI.

CONCLUSIONS

Our study showed that most patients with HHT using nasal self-packings could stop the bleeding after a while. Nasal self-packing is a user-friendly and secure method leaving patients more self-confident and independent.

Virome Analysis Reveals No Association of Head and Neck Vascular Anomalies with an Active Viral Infection

BACKGROUND/AIM

Vascular anomalies encompass different vascular malformations [arteriovenous (AVM), lymphatic (LM), venous lymphatic (VLM), venous (VM)] and vascular tumors such as hemangiomas (HA). The pathogenesis of vascular anomalies is still poorly understood. Viral infection was speculated as a possible underlying cause.

MATERIALS AND METHODS

A total of 13 human vascular anomalies and three human skin control tissues were used for viral analysis. RNA derived from AVM (n=4) and normal skin control (n=3) tissues was evaluated by RNA sequencing. The Virome Capture Sequencing Platform for Vertebrate Viruses (VirCapSeq-VERT) was deployed on 10 tissues with vascular anomalies (2×AVM, 1×HA, 1×LM, 2×VLM, 4×VM).

RESULTS

RNA sequencing did not show any correlation of AVM with viral infection. By deploying VirCapSeq-VERT, no consistent viral association was seen in the tested tissues.

CONCLUSION

The analysis does not point to the presence of an active viral infection in vascular anomalies. However, transient earlier viral infections, e.g. during pregnancy, cannot be excluded with this approach.

Intraoral electrical muscle stimulation in the treatment of snoring

The tone of the intraoral und pharyngeal muscles of the upper airway is of particular importance for the development of snoring. By increasing the tone with electrical stimulation, a reduction in snoring may be achieved. The aim of the study was to record the effects of intraoral muscle stimulation during the day on snoring at night. The prospective bi-centric study included 16 patients with snoring and mild obstructive sleep apnoea (Apnoea Hypopnoea Index [AHI] < 15, BMI < 32). After initial polygraphy, snoring was monitored over 2 weeks (baseline) using a visual analogue scale (VAS; 0-10). This was followed by a 6-week treatment phase (2 × 20 min daily) with an intraoral electrical stimulation device. During and up to 2 weeks after therapy, snoring intensity in addition to use and potential side effects were documented on a daily basis. Three patients discontinued therapy because of technical problems. The 13 remaining patients (11 male/2 female, BMI 26.9 ± 3.2, AHI 9.3 ± 4.6) underwent per-protocol analysis. The mean snoring score was reduced from 5.6 ± 1.1 (baseline) to 3.2 ± 2.7 (after therapy) and remained stable until 2 weeks after treatment (3.3 ± 2.4). In 7 patients (53.9%) the score was reduced by more than 50%. Patients with an AHI < 10 responded better to therapy. No unexpected events occurred. In the present pilot study, the first signs of the effectiveness of intraoral muscle stimulation in snoring patients were shown. In addition to a technical improvement of the stimulator, carrying out controlled trials and assessing potential influencing factors on the success of therapy are necessary.