Severe progressive sensorineural hearing loss improved after removal of large jugular foramen schwannoma

We report a very rare case of hearing improvement after removal of the intracranial part of a jugular foramen schwannoma (JFS) presenting with chronic and severe progressive sensorineural hearing loss (SNHL). The patient presented with progressive hearing impairment in his right ear, lasting 2 years. The patient's pure tone audiogram revealed severe SNHL. His speech discrimination score (SDS) was 0%. Auditory-evoked brain responses (ABRs) comprised only I waves following 30-100dB stimulation, although distortion-product otoacoustic emissions (DPOAEs) had good responses. These test results indicated that his hearing impairment was retrocochlear SNHL. Magnetic resonance imaging revealed within the right jugular foramen a large intracranial-extracranial tumor that compressed the brainstem. The intracranial part of the tumor was resected through retrosigmoidal craniotomy, and the tumor was pathologically diagnosed as a schwannoma. Several months after the operation, the patient's auditory thresholds improved to a level consistent with mild SNHL, ABR V waves emerged following 60-90dB stimulation, and SDS improved significantly to 95%. This case demonstrates that hearing improvement can be achieved after surgery for JFS presenting with severe and chronic progressive SNHL, and that good DPOAE responses and the presence of ABR I waves may be predictors of postoperative hearing recovery in JFS.

[Chronic pain therapy for patients with head and neck tumors]

Patients with tumors of the head and neck region commonly suffer from chronic pain, which is often treated insufficiently. Pain management according to the WHO analgesic ladder can effectively reduce pain in most patients. For head and neck cancer, specific aspects of tumor localization and psychosocial factors must be taken into consideration.

Pediatric head and neck lesions: assessment of vascularity by MR digital subtraction angiography

BACKGROUND AND PURPOSE

Pediatric head and neck lesions can be difficult to characterize on clinical grounds alone. We investigated the use of dynamic MR digital subtraction angiography as a noninvasive adjunct for the assessment of the vascularity of these abnormalities.

METHODS

Twelve patients (age range, 2 days to 16 years) with known or suspected vascular abnormalities were studied. Routine MR imaging, time-of-flight MR angiography, and MR digital subtraction angiography were performed in all patients. The dynamic sequence was acquired in two planes at one frame per second by using a thick section (6-10 cm) selective radio-frequency spoiled fast gradient-echo sequence and an IV administered bolus of contrast material. The images were subtracted from a preliminary mask sequence and viewed as a video-inverted cine loop.

RESULTS

In all cases, MR digital subtraction angiography was successfully performed. The technique showed the following: 1) slow flow lesions (two choroidal angiomas, eyelid hemangioma, and scalp venous malformation); 2) high flow lesions that were not always suspected by clinical examination alone (parotid hemangioma, scalp, occipital, and eyelid arteriovenous malformations plus a palatal teratoma); 3) a hypovascular tumor for which a biopsy could be safely performed (Burkitt lymphoma); and 4) a hypervascular tumor of the palate (cystic teratoma).

CONCLUSION

Our early experience suggests that MR digital subtraction angiography can be reliably performed in children of all ages without complication. The technique provided a noninvasive assessment of the vascularity of each lesion that could not always have been predicted on the basis of clinical examination or routine MR imaging alone.

Photodynamic effects of anthracyclin derivatives on squamous cell carcinoma cell lines of the head and neck

BACKGROUND AND OBJECTIVE

In the last years, photodynamic therapy, performed with hematoporphyrin derivatives, gained in importance for the treatment of superficially situated malignomas. The use of hematoporphyrin as photosensitizer is limited especially by the low depth of penetration and its side effects. The aim of the present study was to evaluate the effectiveness of photodynamic therapy with anthracyclin derivates in squamous cell carcinoma cell lines.

STUDY DESIGN/MATERIALS AND METHODS

The photodynamic effects of the anthracyclin derivates adriamycin and epirubicin as well as the effects of the hematoporphyrin derivatives photofrin-II and photosan-3 were examined and compared in 10 squamous cell carcinoma cell lines derived from head and neck tumors.

RESULTS

Beside their cytostatic effect, the applied cytostatics revealed a marked photodynamic effect. A statistically significant difference for photodynamic effects of both cytostatic agents and the hematoporphyrin derivates could not be shown.

CONCLUSIONS

These results revealed that the above mentioned cytostatics could be considered as possible alternative photosensitizer for photodynamic therapy.

[Neurophysiologic intraoperative monitoring to preserve cranial nerve function in base of skull surgery]

BACKGROUND

Neurophysiologic intraoperative monitoring (NIM) has gone through a renaissance since the advent of computer technology. Currently, both motor and sensory cranial nerves, including the IInd and VIIIth cranial nerves, can be intraoperatively controlled by means of small and mobile systems.

PATIENTS AND METHODS

In order to estimate the value of NIM using the new generation of computer systems, we analyzed the records of 379 patients who underwent skull base surgery since 1996. These comprised NIM of the IInd, VIIth, VIIIth cranial nerves in most cases and of the IXth, Xth, XIth, and XIIth cranial nerves in selected cases.

RESULTS

Whereas 72% of these cases demonstrated changes in the recorded intraoperative NIM signals, only 29% of them gave evidence of either clinical or electrophysiological neural function alterations during the postoperative follow-up.

CONCLUSIONS

NIM is the only available system capable of providing the surgeon with instant intraoperative neural status-related feedback.

[Haemostatic disorders in ENT patients. Part 2: Pathophysiology, diagnostics, clinical feature and therapy]

In the first part of the medical education article on haemostatic disorders in ENT patients the basic physiology of haemostasis and main diagnostic tools were presented and discussed. The second part presents disorders of the coagulation system,thrombocyte function and blood vessels with special emphasis on clinical practice in ENT surgery. In this context, haemophilia A and B, von Willebrand disease and different forms of thrombocytopenia are of main clinical importance. Some underlying diseases such as malignomas, renal and hepatic insufficiency in combination with drug therapy (e.g.anticoagulants and thrombocyte function inhibitors) play an important role in clinical practice as well. Sepsis and haemorrhage may lead to disseminated intravascular coagulation (DIC). Beside a systematic review, important haemostatic disorders are illustrated with case reports.

Sensitization of head and neck squamous cell carcinoma cells to Fas-mediated apoptosis by the inhibition of Bcl-X(L) expression

BACKGROUND

Various types of malignant tumor cells are known to acquire resistance to Fas receptor (Fas)-mediated apoptosis. In Fas-sensitive cells, Fas-mediated apoptosis is observed when anti-Fas antibody is bound to Fas. Bcl-2 and Bcl-X(L) are representative anti-apoptosis proteins reported to be capable of suppressing Fas-mediated apoptosis.

OBJECTIVE

To investigate the mechanism of resistance acquisition to Fas-mediated apoptosis in cultured human head and neck squamous cell carcinoma cells (HNSCCs).

METHODS AND RESULTS

We applied an anti-Fas antibody (CH11) to Fas-expressing HNSCCs (HSC-2) and the CH11 did not induce cell death in HSC-2. Treatment with actinomycin D (ActD) converted the phenotypes of HSC-2 from CH11-resistant to CH11-sensitive. Western blot analysis showed no differences between ActD-treated and ActD-untreated HSC-2 in the expression of Bcl-2. On the other hand, the expression of Bcl-X(L) was greatly reduced in ActD-treated HSC-2. Moreover, the reduction of Bcl-X(L) by specific antisense oligonucleotide treatment enhanced the CH11-induced cell death of HSC-2.

CONCLUSION

Our data suggest that Fas-signaling might be regulated by a Bcl-X(L)-inhibitable step in CH11-resistant HSC-2.

[Mucins in otorhinolaryngology]

BACKGROUND

Mucins are glycoproteins of high-polymer structure. They are an important component of the mucous layer covering the epithelia of the upper aerodigestive tract. Until now there has been little interest with regard to mucins in otorhinolaryngology.

METHODS

The present knowledge about mucins of the upper aerodigestive tract is presented. A MEDLINE search was conducted for English- and German-language articles published from 1966 to the present.

RESULTS

Thirteen different mucins named MUC 1-13 have been subdivided based on the classification system used by the Human Gene Mapping Committee. Besides mucins, small mucin-associated peptides, called trefoil factor peptides, have attracted much interest.

CONCLUSIONS

Classification and attribution of the mucins found in the middle ear, larynx, oropharynx, esophagus, and nasolacrimal ducts has yet to be done. Also, little is known about the distribution of trefoil factor peptides in the upper aerodigestive tract.

Dedifferentiated liposarcoma of the pyriform sinus: report of a case and review of the literature

Laryngeal and hypopharyngeal liposarcomas are extraordinarily infrequent tumors. To the best of our knowledge there are fewer than 40 well-documented cases reported to date. Almost all of them are well-differentiated liposarcomas, with only 2 laryngeal-hypopharyngeal dedifferentiated liposarcomas. Dedifferentiated liposarcoma is defined as a well-differentiated liposarcoma with areas of high-grade spindle cell nonlipogenic sarcoma. The well-differentiated areas may be of a lipoma-like, sclerosing, or mixed type, and the dedifferentiated areas most frequently are of malignant fibrous hystiocytoma-like type. Despite its commonly pleomorphic histology, dedifferentiated liposarcoma does not behave as aggressively as most pleomorphic sarcomas of adulthood; however, it has the capacity to metastasize, in contrast to its well-differentiated counterpart. We present a case of dedifferentiated liposarcoma arising in the pyriform sinus, an event only twice reported previously in the literature.

Quantitative analysis of the drainage after neck dissection

The goals of this study are to determine the normal volume and lipid values of the drainage after neck dissection (ND) and to evaluate the changes of these values according to the type and side of the ND. Ninety-seven uncomplicated NDs involving zones I through IV were evaluated prospectively in this study. The most important result of the analysis of the drainage is that levels of triglyceride and cholesterol in the drainage were lower than serum levels in all but 1 case (P< 0.001). When matched for the type and side of the dissection, only mean total drainage volume was significantly higher in radical NDs than in selective NDs (P = 0.001). The normal volume and lipid values of neck drainage are reported in this study. Being aware of the changes in these values may help early diagnosis of some pathologic conditions.

Reproducibility of technetium-99m-MAG3 clearance using the Bubeck method

The objective of this study was to estimate the reproducibility of 99mTc-mercaptoacetyltriglycine (99mTc-MAG3) clearance calculated using a single-sample method.

METHODS

One hundred forty-seven patients with urological or ear, nose and throat cancer were analyzed in a retrospective study. Each patient had at least two clearance studies with 99mTc-MAG3 before chemotherapy treatments to monitor renal function. Up to five clearance studies per patient were considered. The reproducibility was estimated by comparing two consecutive investigations. Pairs of investigations with a change in split renal function of more than 5% or an interval of more than 50 days were excluded. Clearance was determined using the Bubeck method. For each pair of consecutive clearance data, the difference between the first and the second measurements was expressed as a percentage of the mean value of the two measurements. The mean of these normalized differences represents the systematic deviation, and the s.d. represents the reproducibility of the compared clearances.

RESULTS

After the selection, 242 pairs of consecutive clearance data remained for comparison. Significantly different clearances were observed only between investigations 0 and 1 and between 4 and 5. The systematic deviation of these comparisons totaled -3.8% and -5.7%, respectively. In the other comparisons, no significant deviation induced by the chemotherapy was found. The reproducibility calculated for all comparisons totaled 11.7%.

CONCLUSION

The error of reproducibility of 99mTc-MAG3 clearance using the Bubeck method was < or =11.7%. This was an acceptable value, taking into account the greater fluctuation of tubular function compared with the glomerular filtration rate.

The infected wound and its management

The infected wound is one of the most frequent causes of delayed wound healing. Even in the face of appropriate antibiotic prophylaxis, infections can occur in 10% to 20% of clean-contaminated procedures in the head and neck. The authors describe their comprehensive approach to prevent and manage the infected wound at the head and neck area.

[Prognosis of epidermoid carcinoma of oropharyngeolaryngeal region]

Knowledge of pronostic factors is essential for assessment of therapeutic procedures and for individual treatment selection and adjustment for patient with squamous cell carcinomas of the head and neck. This paper reviews known clinical, histological and biological prognostic factors and their prognostic significance in predicting survival, response to treatment and locoregional and distant recurrences. Most significant criteria include tumor site and extension, absence or presence of cervical lymph nodes and their location, size and mobility. Histological, disease-related factors include number and location of involved nodes, and extra-capsular spread, which is the most significant independent factor. Response to treatment is an essential factor which should be used to alter or complement the treatment plan. Other treatment-related factors include technical parameters that can impact the outcomes and should be taken into account when assessing treatment procedures. Preliminary studies suggest that biological factors may be used as efficient predictors within the next few years but they are still under evaluation and therefore are not to be used in routine practice. They are expected to improve prediction of response to radiotherapy and chemotherapy as well as prediction of the risk of distant metastases and of metachronous head and neck cancers.

[Intraoperative monitoring of motor cranial nerves in operations of the neck and cranial base]

Intraoperative monitoring of cranial nerves is performed to minimize postoperative cranial nerve dysfunction. We performed electrophysiological monitoring of motor cranial nerves with a NIM 2 unit from Xomed Treace and a patient multiplexer developed in our clinic. This multiplexer allows simultaneous monitoring of 4 cranial nerves and is additionally equipped with a bipolar stimulation mode. This intraoperative monitoring was employed during 102 skull base operations. Of these 102 operations, 44 were acoustic neuroma removals by translabyrinthine approach and 36 by a middle fossa approach. Various operations including removal of tumours of the jugular foramen and the infratemporal fossa were performed in the remaining 22 patients. The facial nerve, being the most frequently monitored nerve, was evaluated both pre- and intraoperatively. Electrophysiologic data were evaluated with respect to their predictive value for postoperative facial nerve function. The relative per cent decrease in amplitude of the EMG after resection compared to that observed before resection seems to be of some predictive value for postoperative facial nerve function. A 50-60% decrease or more is associated with an increase in the House classification. Intraoperative monitoring is a useful tool in skull base surgery allowing for safer and faster identification of motor nerves in pathologic anatomic conditions. It allows the surgeon a degree of comfort by providing immediate information regarding the status of the nerve. It may also improve post-operative nerve function and shorten operating time. Additionally, neuromonitoring provides some information about expected postoperative facial nerve function.

[Adjuvant and drug therapy of chronic pain in the head and neck area]

Head and neck pain caused of benign or malignant disease reduces remarkable the patient's quality of life. In the following are presented adjuvant and medicamentous methods for pain control. Surgery, irradiation and chemotherapy aim to diminish the tumor extension and reduce algesic transmitting substances in the periphery. Nerve blocs, cryoanalgesia and transcutaneous electrical nerve stimulation lead to an interruption of the painful spinal reflex arc. Active, passive and relaxation exercises prevent from dolorific muscular tensions. Psychological treatment, so as relaxation techniques in connection with behavior therapy, helps to develop coping strategies. The mainstay of pain relief is effective use of analgetics which should be given orally if possible, on a regular schedule and on an individualized basis according with the WHO guidelines.

[Drug and non-drug tumor pain therapy in ENT medicine]

The basic of analgesic therapy in patients with advanced cancer of the head and neck is the regular application of analgesics and adjuvant analgesics. Radiotherapy is the treatment of choice in patients suffering from severe pain by bone metastases. Analgesic-resistant pain of dura in patients with tumour infiltration of the skull base is an indication for intraventricularly application of opioids by neurosurgeon.

[The effect of functional impairments and autonomic symptoms on the quality of life after the therapy of tumors in the ENT area]

Life quality in tumour patients has received growing scientific and public attention. While most studies focus on patients with tumours in the thorax or abdomen, less is known about determinants of life quality in patients with tumours in the head-neck region. In this report, we focus on the role of tumour localisation, clinical staging, functional impairments, and vegetative symptoms on the rating of life quality. In a structured interview, 222 tumour patients regularly followed-up by the Department of Otorhinolaryngology were asked about aspects of their illness, especially with regard to life quality. The results show that clinical stage of tumour had an U-shaped effect on life quality. Patients on stage 1 or on stage 3 had higher life quality ratings than patients on stage 2, which may indicate divergent coping styles of the patients. Patients with impairments of swallowing, tasting, whispering or breathing rated significant lower on life quality. Moreover, patients suffering from pain, with sleeping problems, with impairments of their bodily appearance or of their sex life rated significantly lower on life quality. Tumour localisation had no effect on ratings of life quality. In conclusion, it can be stated that life quality of tumour patients in otorhinolaryngology is influenced by clinical stage of the tumour, functional impairments and vegetative symptoms.

[Treatment of intractable pain in ORL cancer]

Numerous effective treatments are available to relieve the intractable pain of terminal E.N.T. cancers when aetiological therapies are no longer of any use. These treatments must be prescribed as a progressive therapeutic scale ranging from analgesics, and notably morphine which remains the basic drug, to the classical or stereotactic surgical operations. To these must now be added other routes of administration of morphine (e.g. intraventricularly) which in some cases give unexpected results.