[Pathological changes of the chemosensory function in multiple sclerosis - an MRI study]

PURPOSE

To examine possible causes for olfactory and gustatory dysfunction in MS patients in a prospective study with MRI.

MATERIALS AND METHODS

30 MS patients (21 women, 11 men, 22 - 65 years, Ø 42 years) were examined by MRI. The olfactory bulb (OB) and olfactory brain volume was correlated with the number and volume of MS lesions in the olfactory brain and the non-olfactory brain. Olfactory testing was performed using the Threshold-Discrimination-Identification Test (TDI), and gustatory function was tested using the Taste-Strips-Test (TST).

RESULTS

33 % of the MS patients displayed olfactory dysfunction (8 % of the control group), and 17 % displayed gustatory dysfunction (5 % of the control group). There was a correlation between the olfactory brain volume and the number (r = -0.38, p < 0.05) and volume (r = -0.38, p < 0.05) of MS lesions in the olfactory brain. The olfactory brain volume correlated with the number of MS lesions in the non-olfactory brain (r = -0.48, p < 0.05). The volume of the left OB correlated with the volume of MS lesions in the olfactory brain (r = -0.42, p < 0.05), the number (r = 0.37, p < 0.05) and volume (r = 0.4, p < 0.05) of lesions in the left part of the olfactory brain and with the TST score (r = -0.45, p < 0.05). The TST score correlated with the volume of lesions in the left (r = -0.45, p < 0.05) and right part (r = -0.53, p < 0.05) of the olfactory brain. The TST score correlated with the number of lesions in the non-olfactory brain (r = -0.48, p < 0.05).

CONCLUSION

The correlation between a higher number and volume of MS lesions in the olfactory brain with a decreased OB and olfactory brain volume could help to explain olfactory and gustatory dysfunction in MS patients. Just the left OB correlated with the number and volume of lesions in the olfactory brain. Manual segmentation was a suitable method for measuring OB and olfactory brain volume.

[Process optimization in ENT: clinical pathways and central induction area]

INTRODUCTION

Owing to the rising costs in the health care system, it is now important to optimize processes through standardization and process consolidation. A lack of process consolidation in this area of operation or overly long durations of stay of patients in the hospital can lead to increased costs for the ENT department. The aim of this study was to examine whether process optimization could be achieved through close interdisciplinary networking with clinical pathways and central induction (CI).

MATERIAL AND METHODOLOGY

In the 1-year periods before and after the implementation of CI, turnover times in the ENT department were retrospectively examined and 2,433 patients from the entire operative ENT spectrum were included. The average durations of stay before and after the implementation of the "septoplasty" pathway were additionally evaluated.

RESULTS

ENT turnover times were significantly reduced after the introduction of CI. In comparison to the conventional anaesthesia process, the turnover times using CI were on average 10 min shorter. Furthermore, since the introduction of pathways, the duration of stay for ENT patients could be significantly reduced while simultaneously maintaining the quality of care. This process was statistically evaluated using septoplasty in nasal surgery as a typical example and the duration of stay was reduced from 5.85 days to 4.32 (a reduction of 26%) or 3.55 days (a reduction of 34%).

CONCLUSIONS

The combination of CI and pathways is a suitable means to increase the clinical and economic effectiveness even when the new case-based flat-rate system is taken into consideration.

[Olfactory dysfunction: correlation of olfactory bulb volume on MRI and objective olfactometry]

PURPOSE

To define the role of olfactory bulb volume measurement by magnetic resonance imaging (MRI) for detecting olfactory dysfunction in comparison with objective olfactometry.

MATERIALS AND METHODS

Thirty patients with suspected olfactory dysfunction (16 women, 14 men; mean age 52 years, range 20 - 79 years) were examined by MRI and objective olfactometry between January 2006 and January 2009. Olfactory bulb volumes were measured by two neuroradiologists using 3D MR data sets. The olfactory function was categorized as normosmia, hyposmia, and anosmia on the basis of objective olfactometry. Pearson correlation coefficients were calculated for objective olfactometry and olfactory bulb volumes on MRI. ROC analysis was performed to determine whether MRI bulb volumes can serve to predict anosmia or hyposmia.

RESULTS

The bulb volumes measured by MRI ranged from 0 to 135.9 mm (3). Based on olfactometry, anosmia was present in 11 patients (total bulb volume of 15.7 +/- 23.3 mm (3)), hyposmia in 9 patients (total bulb volume of 50.0 +/- 25.5 mm (3)), and normosmia in 10 patients (total bulb volume of 110.7 +/- 21.5 mm (3)). There was good correlation (r > 0.9) between objective olfactometry and olfactory bulb volume on MRI. ROC analysis yielded a cut-off value of 32 mm (3) for anosmia, which had a sensitivity of 0.91 and specificity of 0.947. The cut-off value for olfactory dysfunction was 80.7 mm (3) (sensitivity 0.95; specificity of 0.9).

CONCLUSION

The olfactory bulb volume determined by MRI is a suitable parameter for diagnosing complete or partial loss of the sense of smell.

The improvement of middle ear ventilation by laser ablation of the epipharyngeal eustachian tube: a prospective study

A long-lasting dysfunction of the eustachian tube seems to be the etiologic origin for development of chronic otitis media (COM) with mesotympanic perforation, otitis media with effusion (OME), and chronic atelectasis of the middle ear. Surgical interventions in the middle ear generally treat the sequelae of the tube dysfunction but not the dysfunction itself. This prospective clinical study investigated how far fiber-guided laser ablation of the posterior half of the epipharyngeal tubal ostium led to better middle ear ventilation in the otologic disease patterns mentioned below. There were 38 adult patients included in the analysis. The patients in one group had a perforated tympanic membrane [COM before primary tympanoplasty (n = 14) or revision tympanoplasty (n = 5)]; the patients in a second group had an intact eardrum [OME resistant to therapy (n = 3), with an atelectasis of the middle ear (n = 2) or problems of pressure equalization with fast changes in ambient pressure (diving, flying) (n = 14)]. Laser ablation of the posterior half of the epipharyngeal tubal ostium was performed, generally with local anesthesia, if tubal function testing was pathologic (Valsalva maneuver, passive tube opening, tympanogram). In patients with COM the procedure was performed 8 weeks before the middle ear surgery. All patients were checked 8 weeks postoperatively and in the course of the following year. The intervention seemed to have had a positive effect on tube function in 68.4% of patients operated on (P = 0.001). In 26 of the 38 patients that had undergone operation, an improvement the results of tubal function tests could be seen in the postoperative follow-up. In the COM group the Valsalva maneuver improved in 14 of 19 patients (73.6%) (P = 0.001), and the passive tube opening improved in nine of 18 patients (50%). In the group with an intact eardrum the Valsalva maneuver improved in 13 of 18 patients (72.2%) (P = 0.001). The resulting condition remained stable after 1 year. None of the patients showed any complications as a result of the therapy. Minimally invasive shaping of the distal eustachian tube under topical anesthesia can be recommended for patients with the above-mentioned diagnoses who have pathologic middle ear ventilation. Especially prior to tympanoplasties, and especially in otologic revision procedures, where middle ear ventilation is a prerequisite for successful otologic surgery, the function of the eustachian tube can be optimized in 70% of the patients, particularly if there are pathological findings (tubal tonsil, narrow orifice of the tubal ostium, adenoids). The placement of permanent ear tubes in adults with recurrent OME can also be avoided by the procedure described. The resultant conditions remained stable for the next year. Patients with tympanic ventilation problems due to rapid pressure changes (flying, diving) can also benefit from this procedure.

[The punctum plug as an option for treating retrograde air flow from the lacrimal sac]

BACKGROUND

The causes of keratoconjunctivitis sicca are multifarious. Major causes include eyelid anomalies, Sjögren's disease, injuries, radiation or mucin deficiency. In our case, nasal positive airway pressure due to muscular dystrophy is described as another possible cause.

PATIENT

A 32-year-old male patient with advanced Duchenne muscular dystrophy requires nasal continuous positive airway pressure ventilation due to loss of the auxiliary respiratory muscles. The patient presented because permanent air flow from the lower right lacrimal point resulted in epiphora and keratoconjunctivitis sicca on the right side.

THERAPY

We reversibly occluded the lower lacrimal duct with a punctum plug flow regulator. The lacrimal flow regulator is available in two sizes, 0.8 and 0.9 mm, and is designed to be inserted into the punctal aperture. The soft silicone plug is delivered with a disposable dilator and can be used on an outpatient basis. It is actually used for punctal occlusion in patients with chronic dry eye syndrome and regulates the flow of lacrimal fluid. After insertion of a 0.9 mm punctal plug, the patient reported marked improvement of the findings, which was confirmed in a follow-up after 4 and 8 weeks. On a visual analog scale of 1 to 10, the subjective status was given a rating of 8.

CONCLUSION

By occluding the right lower lacrimal point with a punctal plug, we were able to markedly reduce the unpleasant retrograde air flow and the subjective complaints of the patient with nasal continuous positive airway pressure ventilation.

[Neurilemmoma of the head and neck--report of 3 cases]

BACKGROUND

Neurilemmoma are benign tumors of the nerve-sheath, also known as schwannoma. Beside intracranial manifestation, neurilemmoma are found at other peripheral nerves of the head and neck.

CASE REPORT

We present three cases of patients with seldom manifestation of neurilemmoma of the supraglottis, the retropharyngeal space and a neurilemmoma of the hypoglossal nerve. The histological examination showed two types of Antoni-A-neurilemmoma, whereas one tumor was found with mixed type A and B-neurilemmoma.

CONCLUSION

Although extracranial neurilemmoma of retropharygeal space, neck or supraglottic larynx are rare tumors, neurilemmoma should be involved in differential diagnosis of tumors in these areas. The therapy of choice consists of complete surgical removal and histological examination.

Spatial organisation of microbiota in quiescent adenoiditis and tonsillitis

BACKGROUND

The reasons for recurrent adenotonsillitis are poorly understood.

METHODS

The in situ composition of microbiota of nasal (5 children, 25 adults) and of hypertrophied adenoid and tonsillar tissue (50 children, 20 adults) was investigated using a broad range of fluorescent oligonucleotide probes targeted to bacterial rRNA. None of the patients had clinical signs of infection at the time of surgery.

RESULTS

Multiple foci of ongoing purulent infections were found within hypertrophied adenoid and tonsillar tissue in 83% of patients, including islands and lawns of bacteria adherent to the epithelium, with concomitant marked inflammatory response, fissures filled with bacteria and pus, and diffuse infiltration of the tonsils by bacteria, microabscesses, and macrophages containing phagocytosed microorganisms. Haemophilusinfluenzae mainly diffusely infiltrated the tissue, Streptococcus and Bacteroides were typically found in fissures, and Fusobacteria,Pseudomonas and Burkholderia were exclusively located within adherent bacterial layers and infiltrates. The microbiota were always polymicrobial.

CONCLUSIONS

Purulent processes persist during asymptomatic periods of adenotonsillitis. Most bacteria involved in this process are covered by a thick inflammatory infiltrate, are deeply invading, or are located within macrophages. The distribution of the bacteria within tonsils may be responsible for the failure of antibiotic treatment.

[Rehabilitation of the olfactory sense after laryngectomy -- the larynx bypass]

BACKGROUND

Patients after laryngectomy lose their previous sense of smell, since air normally circulates via the tracheostoma and active air intake through the nose is no longer possible. The larynx bypass with a throat mask is an aid here. Nasal air circulation is made possible by this connecting piece between the mouth and tracheostoma.

MATERIALS AND METHODS

Twenty patients (17 men and 3 women, mean age 60 years) who underwent laryngectomy between November 2003 and February 2004 were examined using Sniffin' Sticks with and without the larynx bypass. Moreover, patients were asked about the practicability of the larynx bypass using a visual analog scale (VAS). In addition to larynx bypass function, we were also interested in the handling for the laryngectomized patients.

RESULTS

Overall, patients were able to correctly identify more items with the larynx bypass. The results were significantly better with than without the larynx bypass (p < 0.001). However, the first application of the larynx bypass was considered cumbersome. The median VAS was 5.

CONCLUSION

Patients had a better sense of smell with the larynx bypass. However, due to its rather moderate practicability, the larynx bypass does not seem to be suited for daily use in its present form.

[Effects of systemic or topical administration of corticosteroids and vitamin B in patients with olfactory loss]

BACKGROUND

Aim of the present, unblinded, multicentric, open trial was to compare effects of 3 treatments in patients with olfactory dysfunction.

METHODS

Treatments included administration of systemic corticosteroids (oral prednisolone), local corticosteroids (mometasone nasal spray), and systemic vitamin B, respectively. A total of 192 patients participated (95 women, 97 men; mean age 56 years). Duration of the smell loss ranged from 1 to 288 months (average 45 months). Olfactory dysfunction was due to infections of the upper respiratory tract (n = 72), sinunasal disease (n = 19), and posttraumatic olfactory loss (n = 10); the largest portion was classified as idiopathic (n = 85); other causes were rare (n = 6).

RESULTS

Following systemic administration of corticosteroids improvement of olfactory function was observed (p < 0.001). Similarly, improvement of the sense of smell was found 2 (p = 0.03) and 6 months (p = 0.001) after local administration of mometasone, respectively. In contrast, after administration of vitamin B no significant change of olfactory function was seen after 2 months, while improvement was present after 6 months (p = 0.001). Duration of olfactory dysfunction had no effect on changes of smell function.

CONCLUSIONS

These results indicate that improvement of olfactory function is found in olfactory dysfunction of different causes. Adequately controlled, blinded studies are needed to further explore potential effects of the various treatments.

[Wegener's granulomatosis (WG) presented with hearing loss and without positive serologic ANCA]

BACKGROUND

Wegener's granulomatosis (WG) is a granulomatous inflammation involving the upper and lower respiratory tract and necrotizing vasculitis affecting small to medium-sized vessels. In contrast to a generalised WG with glomerulonephritis initial or isolated forms of the upper respiratory tract may be a diagnostic challenge.

PATIENT

We report the case of a 33 year old man with clinical signs of a limited WG exhibiting an imminent irreversible hearing loss, negative PR3-ANCA (anti neutrophil cytoplasmic antibodies with proteinase 3 as target) in serum and an ambiguous histology.

CONCLUSION

In case of a chronic otitis media and rhinitis as well as signs of a labyrinthine deafness a limited form of a WG has to be taken into account, even with an ambiguous histology and negative PR3-ANCA. This diagnosis is supported by high inflammation parameters, e. g. ESR and CRP, exclusion of infectious cause and response to corticosteroids. A quick therapeutic intervention with corticosteroids and cyclophosphamide is required in order to interrupt the vasculitis of the inner ear with consequential deafness.