LymphoDose: a lymphocyte dose estimation framework-application to brain radiotherapy

Objective. Severe radiation-induced lymphopenia occurs in 40% of patients treated for primary brain tumors and is an independent risk factor of poor survival outcomes. We developed anin-silicoframework that estimates the radiation doses received by lymphocytes during volumetric modulated arc therapy brain irradiation.Approach. We implemented a simulation consisting of two interconnected compartmental models describing the slow recirculation of lymphocytes between lymphoid organs (M1) and the bloodstream (M2). We used dosimetry data from 33 patients treated with chemo-radiation for glioblastoma to compare three cases of the model, corresponding to different physical and biological scenarios: (H1) lymphocytes circulation only in the bloodstream i.e. circulation inM2only; (H2) lymphocytes recirculation between lymphoid organs i.e. circulation inM1andM2interconnected; (H3) lymphocytes recirculation between lymphoid organs and deep-learning computed out-of-field (OOF) dose to head and neck (H&N) lymphoid structures. A sensitivity analysis of the model's parameters was also performed.Main results. For H1, H2 and H3 cases respectively, the irradiated fraction of lymphocytes was 99.8 ± 0.7%, 40.4 ± 10.2% et 97.6 ± 2.5%, and the average dose to irradiated pool was 309.9 ± 74.7 mGy, 52.6 ± 21.1 mGy and 265.6 ± 48.5 mGy. The recirculation process considered in the H2 case implied that irradiated lymphocytes were irradiated in the field only 1.58 ± 0.91 times on average after treatment. The OOF irradiation of H&N lymphoid structures considered in H3 was an important contribution to lymphocytes dose. In all cases, the estimated doses are low compared with lymphocytes radiosensitivity, and other mechanisms could explain high prevalence of RIL in patients with brain tumors.Significance. Our framework is the first to take into account OOF doses and recirculation in lymphocyte dose assessment during brain irradiation. Our results demonstrate the need to clarify the indirect effects of irradiation on lymphopenia, in order to potentiate the combination of radio-immunotherapy or the abscopal effect.

Insights on the carbon footprint of radiotherapy in France

The French healthcare system is responsible for 8% of the national footprint. Achieving a net zero emissions scenario will require a 4-5 fold decrease of carbon emissions in the coming years. The carbon footprint of radiation therapy has not been specifically studied to date. In this review we summarize the content of the carbon footprint dedicated session at the annual meeting of the French society of radiation oncology (SFRO). We discuss the French healthcare system carbon footprint and its major drivers and our work on the estimation of the carbon footprint of external beam radiation therapy in the French setting. We developed a dedicated methodology to estimate the carbon footprint related to radiation therapies, and describe the main drivers of emissions based on a single centre as an example, namely patient's rides, accelerators acquisition and maintenance and data storage. Based on the carbon footprint calculated in our centres, we propose mitigation strategies and an estimation of their respective potential. Our results may be extrapolated to other occidental settings by adapting emission factors (kilograms of carbon per item or euro) to other national settings. External beam radiation therapy has a major carbon footprint that may be mitigated in many ways that may impact how radiation therapy treatments are delivered, as well as the national organization of the radiotherapy sector. This needs to be taken into account when thinking about the future of radiotherapy.

[Value of informed consent in tympanoplasty and FESS procedures]

BACKGROUND

More than one third of all lawsuits against surgeons include statements of insufficient or lacking preoperative informed consent which is mandatory in the german jurisprudence. Almost nothing is known about the postoperative patient's memory of risk factors which were explained prior to typical surgical procedures in ENT.

METHODS

The objectives of this prospective study in 201 patients were to elucidate the actual clinical routine of obtaining informed consent for tympanoplasty (n=105) and FESS procedures (n=89), collect information on active and passive recall 6 weeks, 6 months and 1 year post-operatively, and to investigate whether patient age, sex, education, the time from obtaining consent to interview, recurrent vs. non-recurrent procedures, would influence the patient's recall capabilities.

RESULTS

In clinical routine, obtaining informed consent included 5 main items for tympanoplasty and 5 for FESS procedures made by the physician. Of the patients, 18.9% recalled actively and 65.3% passively. They named 1.5 items on average, with "deafness" as the leading complication in tympanoplasty and "amaurosis" in FESS procedures. Patient's memory was depending on the time from obtaining consent to interview and education exclusively.

CONCLUSION

In conclusion, the quantity of patient/physician interaction does not guarantee an increased effect on patient's recall. Improving patient interaction may reduce the probability of imminent accusations.

[Skin prick test results in snoring and sleep apnea patients]

BACKGROUND

In allergic rhinitis, nasal obstruction is a typical symptom. Reduced nasal ventilation is thought to be one causal factor for sleep breathing disorders. Whether or not snoring individuals with or without sleep apnea show more frequent or stronger reactions in skin prick tests (SPT) compared to non-snorers has not been investigated yet.

METHOD

SPT on 20 most frequent allergens and standardized questionnaires of 412 patients of either sex who received a polysomnography at the sleeplab of the ENT department, University of Würzburg, Germany, were analysed retrospectively. In 351 patients (85 %), data were complete. According to their polysomnography, patients were grouped into snorers (n = 248, 71 %) and non-snorers (n = 103, 29 %) or apnea (apnea-hypopnea-index > 10; n = 171, 49 %) and non-apnea patients (n = 180, 51 %). Average occurrence or strength of skin reactions was compared between these groups.

RESULTS

Except plantain (7 % vs. 1 %) and beech (10 % vs. 3 %), there were no statistical increases in the average occurrence or strength of SPT results in snoring individuals. Apnea patients did not show more frequent or stronger allergic skin reactions than non-apnea patients. Three patients suffering from allergic rhinitis by house dust mites were treated with citerizin 10 mg and allergen exposition prophylaxis. Three months after onset of therapy in all three patients, a reduction of snoring was polysomnographically observed. Snorers or apnea patients complaining sneezing, reduced nasal ventilation at night, hyperlacrimation or rhinorrhea showed significant higher numbers of allergic skin reactions for rye, gras and house dust mites compared to patients without these symptoms.

CONCLUSIONS

The results reveal that only snorers or apnea patients with specific symptoms for allergic rhinitis should be tested by SPT. A general SPT-screening seems not to be indicated. Snoring and apneas in patients with allergic rhinitis due to house dust mites can be eliminated or reduced by an oral antihistaminic treatment.

Combined intra-operative monitoring of hearing by means of auditory brainstem responses (ABR) and transtympanic electrocochleography (ECochG) during surgery of intra- and extrameatal acoustic neurinomas

BACKGROUND

Although being established as a standard procedure in intra-operative monitoring in acoustic neurinoma surgery, auditory brainstem responses (ABR) represent a far-field technique bearing some technical limitations. This prospective study was designed to evaluate electrocochleography (ECochG) as a supplementary tool for hearing preservation.

METHOD

84 patients with unilateral intra-/extrameatal acoustic neurinomas (extrameatal diameter: 5-55 mm) preserving serviceable hearing, were operated on using a combined (neuro-/otosurgical) suboccipital approach. ECochG was recorded simultaneously to ABR following transtympanic insertion of a steel needle electrode into the promontory under otoscopic view.

FINDINGS

Serviceable hearing (Class 1-3 according to Gardner/Robertson) was preserved in 43 out of 84 patients (51.2%), of whom 40 showed both ECochG and ABR being preserved. All 24 patients with loss of both modalities became deaf. Hearing preservation was observed in 4 out of 12 patients with preserved ECochG but loss of ABR (waves III-V). The reverse was observed in 2 cases with postoperative deafness. While both ECochG and ABR amplitudes were significantly correlated with pre- and postoperative hearing, latencies of ECochG summating (SP) and action potential (AP) proved to be more reliable indicators for preserved hearing than ABR (peak I/III/V) latencies. The predictive value of baseline ABR amplitudes for postoperative hearing, however, was superior to ECochG parameters. Only in large neurinomas (extrameatal diameter: >2 cm) tumour size was found to be a significant predictor for the preservation of hearing. Apart from three cases with postoperative otoliquorrhea and one further case presenting with local bleeding within the external acoustic meatus, no side effects were observed.

CONCLUSIONS

In combination with ABR monitoring, ECochG proved to be a useful supplementary tool for hearing preservation in acoustic neurinoma surgery. It is particularly helpful during electrocautery and drilling, since no averaging is required. Special applications are: (1) small tumours with good serviceable hearing; (2) and/or a large intrameatal portion; (3) cases with lost or endangered contralateral hearing (e.g. bilateral acoustic neurinomas), when the preservation of poor or even non-functional hearing is desirable.

Intra-operative electromyographic monitoring of the lower cranial motor nerves (LCN IX-XII) in skull base surgery

The functional preservation of lower (motor) cranial nerves (LCN) is endangered during skull base surgery. Intra-operative EMG monitoring of the LCN IX-XII was investigated in 78 patients undergoing 80 operations on various skull base tumors with regard to technical feasibility and clinical efficacy. Ongoing 'spontaneous muscle activity' (SMA) and 'compound muscle action potentials' (CMAP) following supramaximal bipolar stimulation were intra-operatively recorded applying needle electrodes into the soft palate (CN IX: n=76), the vocal cord (CN X: n=72), the trapezius muscle (CN XI: n=18), and the tongue (CN XII: n=71). From 24/22/8 cases with LCN IX/X/XII deficits (despite monitoring) only 5/6/4 remained unchanged (3-6 months postoperative). An irreversible plegia of the LCN IX/X/XII occurred in three (1/1/1) patients. In 7/6/1 patients postoperative (3-6 months) LCN IX/X/XII function was better than preoperatively. In all patients accessory nerve function remained unchanged. 'Pathological' SMA of the LCN IX/X/XII occurred in 12/16/8 cases, but in only 6/5/3 cases corresponded to postoperative LCN deficits. Corresponding 'pathological' SMA patterns were found in 18/17/5 out of 24/22/8 cases with postoperative LCN IX/X/XII dysfunction. Reproducible CMAP of LCN IX/X/XI/XII could be recorded in 59/56/11/32 patients. Approximate 'normal' values were calculated and compared to (very few) data so far given in the literature. Electromyographic monitoring proved to be a safe tool for the intra-operative identification and localization of the LCN contributing to their anatomical and functional preservation. The predictive value of standard neurophysiological parameters for functional outcome, however, is limited.

Acoustic neuroma surgery as an interdisciplinary approach: a neurosurgical series of 508 patients

OBJECTIVES

To evaluate an interdisciplinary concept (neurosurgery/ear, nose, and throat (ENT)) of treating acoustic neuromas with extrameatal extension via the retromastoidal approach. To analyse whether monitoring both facial nerve EMG and BAEP improved the functional outcome in acoustic neuroma surgery.

METHODS

In a series of 508 patients consecutively operated on over a period of 7 years, functional outcome of the facial nerve was evaluated according to the House/Brackmann scale and hearing preservation was classified using the Gardner/Robertson system.

RESULTS

Facial monitoring (396 of 508 operations) and continuous BAEP recording (229 of 399 cases with preserved hearing preoperatively) were performed routinely. With intraoperative monitoring, the rate of excellent/good facial nerve function (House/Brackmann I-II) was 88.7%. Good functional hearing (Gardner/Robertson 1-3) was preserved in 39.8%.

CONCLUSION

Acoustic neuroma surgery via a retrosigmoidal approach is a safe and effective treatment for tumours with extrameatal extension. Functional results can be substantially improved by intraoperative monitoring. The interdisciplinary concept of surgery performed by ENT and neurosurgeons was particularly convincing as each pathoanatomical phase of the operation is performed by a surgeon best acquainted with the regional specialties.

Quantitative parameters of intraoperative electromyography predict facial nerve outcomes for vestibular schwannoma surgery

OBJECTIVE

Facial nerve monitoring is an established method that is routinely used during cerebellopontine angle tumor surgery. The aim of this study was to determine quantitative electromyographic (EMG) parameters that were predictive of facial nerve outcomes.

METHODS

In 137 patients with intra-/extrameatal vestibular schwannomas, the most proximal (the exit from the brainstem) and distal (the fundus of the internal auditory canal) parts of the facial nerve were stimulated after total tumor removal. A quantitative analysis of absolute values and ratios (proximal/distal) of evoked EMG parameters (amplitude, latency, and duration) was performed, and parameters were correlated with postoperative (1 and 6 wk and 6 mo) facial nerve function (FNF).

RESULTS

Absolute values of EMG amplitudes were statistically correlated with FNF (P < 0.05). Amplitude ratios (proximal/distal) demonstrated an even greater predictive power. The risk of exhibiting facial palsy 6 months after surgery increased from 1.6% (amplitude ratio of >0.8) to 75% (ratio of <0.1). For EMG latencies, only the ratios revealed a significant correlation with FNF. The latency ratio-dependent risk of facial palsy after 6 months increased from 2.9% (ratio of <1.05) to 33% (ratio of >1.35). The durations of the muscle responses were not significantly correlated with clinical outcomes.

CONCLUSION

The predictive power of the amplitudes and latencies of electrically evoked muscle responses could be improved by calculating proximal/distal ratios. The proximal/distal amplitude ratio proved to be the most powerful parameter for intraoperative assessment of postoperative FNF.

Technical developments in intra-operative monitoring for the preservation of cranial motor nerves and hearing in skull base surgery

Although EMG recordings from mimic muscles have become the standard for intra-operative facial nerve monitoring, few data are available concerning other motor cranial nerves (MCN). Auditory brainstem responses (ABR) are a proven tool for intra-operative hearing preservation, but have their limitations, suggesting the application of supplementary methods. This paper describes new developments of MCN and cochlear nerve monitoring in skull base surgery. Up to 2 x 8 EMG channels were recorded after bipolar stimulation of MCN using concentric coaxial probes. A special software enabled event-dependent registrations of all signals exceeding a definable threshold level. Selective recordings from masticatory muscles (N.V) were obtained using rectangular Teflon-insulated needle electrodes. For oculomotor (Nn.III/ VI) nerve recordings bipolar needle electrodes were precisely placed by orbital ultrasound guidance. Lower cranial nerves were monitored inserting needle electrodes into the soft palate (N.IX), tongue (N.XII) and vocal muscles (N.X) during laryngoscopy using a special applicator. For ABR recordings, click stimuli (95 dB HL) were applied monaurally through insert earphones. Electrocochleography was simultaneously recorded as a near-field potential without averaging after promontory (transtympanic) electrode placement using otomicroscopy. Regarding the ABR biosignal, a characteristic response pattern was detected following bipolar electrical stimulation of the auditory nerve possibly useful for its intra-operative identification.

[Interesting case no. 20--corpus alienum colli]

We report about a 39-year-old man who presented at the department of ENT Würzburg suffering from a suspicious abscess or tumor of the right neck. Computed tomography and X-ray of the neck did not clarify the entity of the process sufficiently. The emergency surgical exploration of the neck showed an unexpected result: a compress which was forgotten during strumectomy 20 years ago.

[Basic fibroblast growth factor (b-FGF) in the perimatrix of cholesteatoma]

The growth of a cholesteatoma requires angioneogenesis in the connective tissue of the perimatrix. Angioneogenesis is also needed for wound healing as a host response to tissue injury. Normal wound repair is conducted through a wide number of growth factors. Basic fibroblast growth factor (b-FGF) plays a pivotal role in wound repair. This cytokine exerts its effects through stimulation of a wide range of target cells. B-FGF is chemotactic and mitogenic for fibroblasts, endothelial cells and keratinocytes. In addition, b-FGF can stimulate the production of collagenase and plasminogen activators to enhance fibroblast proliferation and angioneogenesis. Its necessity for normal wound repair has been confirmed by several workers.

METHOD

In order to demonstrate angioneogenesis in the cholesteatoma perimatrix the distribution of b-FGF as the pivotal cytokine of the process was investigated in the perimatrix of 18 cholesteatoma specimens.

RESULTS

B-FGF could be observed in 12 of 18 specimens (66%) in close approximation to histological signs of inflammation and wound healing. Areas with b-FGF also exhibited proliferation of the covering squamous epithelium. Cholesteatoma matrix tissue without inflammation or any sign of wound healing did not express b-FGF (6 of 18).

CONCLUSION

Histological changes and distribution pattern of b-FGF in the perimatrix of cholesteatoma in the present study indicate that the perimatrix cells and substances of the wound healing cascade may play an important role in cholesteatoma development, angiogenesis and growth.

[Role of perimatrix fibroblasts in development of acquired middle ear cholesteatoma. A hypothesis]

The epithelial pathogenesis of acquired cholesteatoma has been widely accepted, but clinical and experimental data have not been able to answer questions like: How does a cholesteatoma start or grow or how is bone resorption of conducted? From our own experiments and literature a new hypothesis of cholesteatoma origin and growth is drawn. Three prerequisites are necessary for development: (1) the unique anatomical situation at the ear-drum (two different epithelial layers close together); (2) chronic destruction of the submucosal tissue in the middle ear (infection, inflammation); (3) wound healing (proliferation phase). Destruction of the submucosal space by middle ear infection and cell necrosis starts the wound healing cascade. In wound healing generally the connective tissue fibroblasts and macrophages play a pivotal role. Cytokines of the wound healing thought to promote the re-epithelization of the mucosal defect and scar tissue development act upon the intact squamous cell layer of the outer surface of the ear-drum at the same time. Thereby a proliferation of the undamaged epithelial layer is induced. Cholesteatoma matrix is always surrounded by a layer of connective tissue, the perimatrix. Persistence of the inflammation causes permanent wound healing in the perimatrix, proliferation of the fibroblasts (granulation tissue) and proliferation of the epithelium (matrix). It is speculated that by virtue of wound healing cytokines of fibroblasts and macrophages are the driving forces of cholesteatoma origin, growth and bone destruction.

[Tragus perichondrium-cartilage island transplant in middle ear surgery. Method and results after 5 years]

Temporalis fascia remains the most widespread material for reconstructing the tympanic membrane in tympanomastoid surgery. If total or partial ossicular replacement prostheses are needed or pathology of the eustachian tube causes ventilation impairment, a more rigid transplant material is required. Between 1989 and 1994 perichondrium-cartilage composite grafts were used in a series of 597 cases of tympanomastoid surgery performed at the University ENT Clinic of Würzburg. The graft was taken from the tragus and prepared as a cartilage island with perichondrium attached to one side, the perichondrium-cartilage island transplant (PCI). If reconstruction of the ossicular chain was necessary, glass ionomer cement protheses (IONOS) were used. Closure of the tympanic membrane could be achieved in 90% of all cases. In those cases where ossicular chain reconstruction was postponed to a second procedure, closure of the drum was achieved in 96%. The audiological results of the different type III procedures were evaluated. By using the PCI technique a favorable closure of the air-bone gap to 10-25 dB was achieved, even in cases with advanced ear pathology technique and results are presented in detail.

[Endonasal endoscopic ethmoidectomy in acute therapy refractory sinusitis]

BACKGROUND

Acute sinusitis usually requires conservative treatment with antibiotics and decongestion nose drops. However, a certain number of cases do not respond to that treatment. Because functional endoscopic endonasal sinus surgery (FESS) has been proven to be a valuable tool in treatment of all kind of chronic sinus diseases, it was adopted for acute complicated sinusitis.

METHODS

Between 1990 and 1993, ethmoidectomy was performed in 43 patients with acute inflammatory sinus disease in whom conservative treatment had failed (frontal sinusitis n = 11, max. sinusitis n = 10, isolated ethmoiditis n = 5, orbital complications of sinusitis n = 10, sphenoidsinusitis n = 2, acute pyomucocele n = 5). Coronal CT scan revealed mucosal pathology of the ethmoid region in 41 cases. None of the patients had intranasal polyposis. Complete ethmoidectomy was performed under general anesthesia using an endoscope and the transnasal route.

RESULTS

All patients had relief of their symptoms within the first two postoperative days. One patient with a mucocele and two patients with orbital complications following osteoplastic procedures required revision surgery for removal of screws and plates from previous surgery. None of the patients developed recurrent symptoms of acute complicated sinusitis within the mean postoperative observation period of nine months.

CONCLUSION

FESS should early be considered as a possible treatment of acute sinusitis and its complications if conservative treatment fails.

[Possibilities for preserving hearing in labyrinth fistulas of different degrees of severity]

The labyrinthine fistula continues to be one of the most common complications in ears with cholesteatoma. Fifty-one patients with labyrinthine fistula were identified in a series of 1243 cases with cholesteatoma operated upon between 1989 and 1993 at the University ENT Clinic Wuerzburg. The surgical management concept comprised of removing the cholesteatoma matrix, categorizing the fistula type, and immediate covering of the labyrinthine capsule defect with bone dust, perichondrium and fibrin glue. The classification system of the fistulae used in the study used the depth of labyrinthine involvement as a criterion and also took into account the possibility of intentional or accidental damage to the labyrinth during surgical manipulation (Fig. 1). From 1991 on, patients were treated with 500 mg of Presnisolon 21 hydrogen succinate in a single intravenous dose, at the time the fistula was corrected. The postoperative hearing results were graded based on the extend of preservation of inner ear function at or near the preoperative level. None of the patients who had corticosteroid therapy suffered a profound sensory neural hearing loss (Fig. 2, 3), whereas five ears without steroids and a deep fistula lost function completely. The study concluded that corticosteroids have a beneficial impact on postoperative outcome in cases with severe injury to the membranous labyrinth.

Management of the open labyrinth

Labyrinthine fistulas occur in approximately 5% of cholesteatoma cases, but the management of this difficult problem remains controversial. This study assessed the preoperative presentation and outcome in 37 patients operated on for cholestatoma complicated by labyrinthine fistula. Therapy involved removing the matrix from each fistula and reconstructing the bony wall of the labyrinth with bone dust, fibrin glue, and perichondrium. Corticosteroids were added to the management protocol in more recent cases. A fistula classification scheme was introduced to standardize the reporting of the extent of labyrinthine involvement and results of treatment. The most common preoperative symptoms, sensorineural hearing loss and vertigo, were notably lacking in more than 30% of patients. The fistula test was positive in only 32% of cases. Corticosteroids were seen to have a beneficial impact on postoperative outcome in those cases involving injury to the membranous labyrinth or removal of perilymph.

Management of the Open Labyrinth

Labyrinthine fistulas occur in approximately 5% of cholesteatoma cases, but the management of this difficult problem remains controversial. This study assessed the preoperative presentation and outcome in 37 patients operated on for cholestatoma complicated by labyrinthine fistula. Therapy involved removing the matrix from each fistula and reconstructing the bony wall of the labyrinth with bone dust, fibrin glue, and perichondrium. Corticosteroids were added to the management protocol in more recent cases. A fistula classification scheme was introduced to standardize the reporting of the extent of labyrinthine involvement and results of treatment. The most common preoperative symptoms, sensorineural hearing loss and vertigo, were notably lacking in more than 30% of patients. The fistula test was positive in only 32% of cases. Corticosteroids were seen to have a beneficial impact on postoperative outcome in those cases involving injury to the membranous labyrinth or removal of perilymph.

Composite graft tympanoplasty in the treatment of ears with advanced middle ear pathology

In ears with advanced pathology, the functional and anatomical results of surgery are compromised by such factors as total perforation, tympanosclerosis, atelectasis, suppuration, or previous surgery. Perichondrium cartilage composite grafts (PCCGs) were used for membrane grafting in 550 such cases over a period of 5 years. In all, 197 tympanoplastic procedures of type I (25% with previous surgery) and 353 of type III (47% with previous surgery) were carried out. The graft was obtained from the tragus and/or the concha. Two slightly different surgical techniques of grafting were used. Closure of the eardrum perforation was successful in 92% of the procedures. An air-bone gap of less than or equal to 30 dB was obtained in 92.4% of tympanoplasty type I procedures and in 79% of tympanoplasty type III procedures. The conclusion drawn from the results is that PCCG is a reliable graft in cases of advanced destruction of the middle ear.

[Morphology and clinical aspects of paragangliomas in the area of the head-neck]

Clinical data and tumor specimens from 63 patients were investigated, and included 22 glomus caroticum tumors and 41 tumors of the tympano-jugulare region. All specimens could be differentiated by their histological growth patterns into four categories. The clinical data revealed that 45% of the female patients with paragangliomas suffered from goitre, one of whom died in thyrotoxic crisis after surgery. Two patients died from sequelae of other serious diseases. In general, postoperative morbidity was solely caused by cranial nerve palsies depending on tumor extent. From the data presented, a conclusion is drawn that serious concurrent diseases are the limiting factor for surgery. Early detection is the best way to reduce postoperative morbidity if total removal of the tumor is required.

[Risk of endocrine activation in interventions of paragangliomas in the head-neck area]

The intracytoplasmatic glycolytic enzyme neuron-specific enolase (NSE) can be found in cells of endocrine tissue and their derived tumours. The enzyme is not secreted but released if cells are destroyed, i.e. continuously in malignant tumours. The serum level of neuron-specific enolase (NSE) has been used as a marker for small cell carcinomas of the lung, glioblastomas and malignant phaeochromocytomas. In this investigation blood samples were taken prior to and following surgical manipulation of the tumour in 21 patients with paragangliomas of the head and neck region and 6 controls. 22 serum samples were obtained before angiography and two hours after angiography, 41 before surgery, during surgery and after surgery. The serum level of NSE was measured by NSE-RIA test (Diagnostics, Uppsala). In all tumour specimens NSE could be demonstrated by the immunohistological PAP method (Abb. 1). Only two patients had preoperatively elevated serum-NSE levels. An arterial venous shunt had been detected by angiography in one of these patients. No significant effect on NSE serum level could be produced in the majority of patients by an angiography with embolisation or surgical manipulation of the tumour (Fig. 1, 2). A reduction in serum NSE level was observed postoperatively in both cases mentioned before. None of the 6 controls showed any significant change in serum NSE level (Fig. 3). It can be concluded from this study that embolisation does not lead to direct or indirect cell destruction through ischaemia. Manipulation of the tumour does not destroy a significant number of cells.(ABSTRACT TRUNCATED AT 250 WORDS)

[Esthetic aspects of excision of basaliomas of the area of the head and neck]

Eighty-four patients with basal cell carcinoma of the head and neck were submitted to surgery. In 75%, infiltration of the reticular dermis or the subcutis was documented. Primary closure of the wound was achieved in only one-third of these patients. In the remaining cases, the defects were closed by local flaps, regional flaps or a microvascular forearm flap. In 86% of the cases, good-to-excellent results were achieved.

[Results of tympanoplasty following application of cartilage-perichondrium transplants for tympanic membrane substitution under unfavorable circumstances]

From a series of 2335 cases of ear surgery over a five-year period, the author reports on 550 cases where perichondrium cartilage from the tragus or concha was used as transplant material. Two different surgical techniques were employed. The postoperative gain in hearing and the overall incorporation rate are presented.

[Artificial nutrition with nasogastric catheters. Experiences with a new administration system]

Enteral nutrition via a nasogastric tube is widely used but is inconvenient for patients: the nostril and skin of the nose become irritated and ulcerated, and the tube causes pain and psychological trauma. We have developed a new system which combines the security and ease of nasogastric tube feeding with comfort for the patient. The distal part of the tube is invisibly anchored in the vestibule of the nose, using a special device. The outer part is attached only when feeding is necessary. We report 52 ENT patients who have used this system.

[Treatment of fractures of the orbital floor]

Extensive fractures of the orbital floor are often combined with other fractures of the facial skeleton, and require surgical treatment and reconstruction. In some cases the reconstructed orbital floor needs temporary support from the maxillary sinus to facilitate healing in the correct position. Over a period of 18 months a new low-pressure balloon, made from silicon with a tetrahedron shape, was used in 24 of 47 patients with lateral midface fractures. The post-operative results are presented and the treatment regimen is discussed.

[Merkel cell carcinoma: an endocrine differentiated tumor in the head-neck area]

Merkel's cell carcinomas are rare tumours of the skin, frequently on the head and neck. Electron microscopical and immunohistological techniques are employed for differentiation from other skin malignancies. With two cases the clinical picture, the typical histology and the therapy are elucidated. To detect pathognomic antigen expression, antibodies against Neuron-specific-enolase (NSE) as a marker for endocrine activity and cytokeratin to prove the epithelial character of cells were used (Abb. 4 a,b). The best treatment of Merkel's cell carcinoma is surgical resection, including the regional lymph nodes. Consecutive radiotherapy is strongly recommended.

[Bilateral congenital profound hearing loss and hypospadias--a new syndrome?]

Five children with hypospadia and profound hearing loss were presented to the Clinic for Speech and Communication Disorders of the University of Mainz. Anamnestic and laboratory investigations strongly suggest, that the malformations are interrelated and may represent a new syndrome. Therefore it appears to be helpful to carry out a routine hearing check in children, who are hospitalized for the first surgical treatment of hypospadias.

[The risk of endocrine activation in interventional procedures on paraganglioma of the head and neck]

In the literature on paragangliomas or glomus tumors of the head and neck, the question rarely arises as to whether in endocrine inactive paragangliomas the tumor necrosis resulting from the embolization can release the stored substances. Based on 34 paragangliomas after surgical treatment, the angiographic and immunohistological characteristics of the paraganglionic, angiomatous and adenomatous tumors are presented. No catecholamine secretion occurred as a result of interventional or surgical treatment.

[Immunohistologic findings in paragangliomas in the area of the head and neck]

30 patients with paraganglioma of the head and neck region were subjected to surgery at the Department of Otorhinolaryngology during 1978-1985. Histological classification of the obtained specimens was performed using also immunocytochemical methods to detect more details. The site of origin of the tumours was the glomus tympanicum in 18 cases, 7 times the glomus caroticum and 5 times the glomus jugulare. Antibodies against neuronal components (S-100 protein), endothelial cells (UEAI) and endocrine activity (NSE) were used for subtyping by PAP-method (Figs. 1-3). Immunocytochemistry provided for an easy subtyping of the tumours and showed an increase in severe progress forms in adenomatous variants of paragangliomas.

[Paraneoplastic acrokeratosis: Bazex disease. A tumor-specific dermatosis in squamous cell cancers in the area of the head and neck]

Bazex syndrome is a rare paraneoplastic syndrome with characteristic acral hyperkeratosis, seen only in men with either carcinoma of or metastases to the head and neck. The author describes a case of Bazex syndrome in which recognition of the hyperkeratosis led to diagnosis and treatment of the underlying tumour.

Clinical and morphological aspects of nephrotic syndrome in perimembranous, focally sclerosing and membrano-proliferative glomerulonephritis

The following data was obtained by morphometric and photometric microscopic studies of renal biopsies from 140 patients with idiopathic perimembranous glomerulonephritis, 108 patients with focally sclerosing glomerulonephritis and 50 patients with membranoproliferative glomerulonephritis and correlation of the results obtained with available clinical data: 1. In all three diseases proteinuria and serum protein concentration show no tendency to stabilization in spite of increasing renal insufficiency. 2. With increasing renal insufficiency the proximal tubular cells become increasingly atrophic. 3. Protein resorption through the proximal tubulus cells becomes increasingly diminished with advancing renal insufficiency. It is concluded from the present data that proteinuria, which is primarily glomerular caused, is increased by increasingly diminished resorption of proteins in the tubulus system with increasing renal insufficiency. In this way, even under conditions of advanced renal insufficiency with reduced GFR, large amounts of proteins can be excreted and a nephrotic syndrome can persist to a stage of renal insufficiency.