[Structure and establishment of the German Cochlear Implant Registry]

Hearing rehabilitation of patients with severe hearing loss or deafness using cochlear implants (CI) is a very successful but also complex and lifelong process that requires high quality standards for structure, process, and results. Medical registries represent an ideal tool for conducting quality control relevant to care while at the same time collecting scientific data. Therefore, at the initiative of the Executive Committee of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), a Germany-wide CI registry (the German Cochlear Implant Register, DCIR) was to be established. The following goals were to be achieved: 1) legal and contractual basis for the register; 2) definition of the register contents; 3) development of evaluation standards (hospital-specific and national annual reports); 4) development of a logo; 5) practical operation of the registry. After defining a catalog of services that defines the content, structure, and operation of the DCIR, a registry operator with audiological expertise was sought. After considering various offers, the registry was technically implemented in cooperation with the provider INNOFORCE (Ruggell, Liechtenstein) as registry operator. This also included the realization of an interface for data transfer from previously existing databases and development of a data protection concept for productive operation of the DCIR under the scientific leadership of the DGHNO-KHC Executive Committee. Since January 2022, it has been possible for participating hospitals to enter pseudonymized data into the DCIR. To date, 75 hospitals in Germany have contractually agreed to participate in the registry. During the first 15 months, data from over 2500 implants in over 2000 patients were registered in the DCIR. The work presented here describes the structuring, development, and successful establishment of the DCIR. Introduction of the DCIR represents an important milestone of future scientifically based quality control in CI care. The registry presented here can therefore be considered as an example for other areas of medical care and thus also sets an international standard.

Structure and establishment of the German Cochlear Implant Registry (DCIR)

Hearing rehabilitation of patients with severe hearing loss or deafness using cochlear implants (CI) is a very successful but also complex and lifelong process that requires high quality standards for structure, process, and results. Medical registries represent an ideal tool for conducting quality control relevant to care while at the same time collecting scientific data. Therefore, at the initiative of the Executive Committee of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), a Germany-wide CI registry (the German Cochlear Implant Register, DCIR) was to be established. The following goals were to be achieved: 1) legal and contractual basis for the register; 2) definition of the register contents; 3) development of evaluation standards (hospital-specific and national annual reports); 4) development of a logo; 5) practical operation of the registry. After defining a catalog of services that defines the content, structure, and operation of the DCIR, a registry operator with audiological expertise was sought. After considering various offers, the registry was technically implemented in cooperation with the provider INNOFORCE (Ruggell, Liechtenstein) as registry operator. This also included the realization of an interface for data transfer from previously existing databases and development of a data protection concept for productive operation of the DCIR under the scientific leadership of the DGHNO-KHC Executive Committee. Since January 2022, it has been possible for participating hospitals to enter pseudonymized data into the DCIR. To date, 75 hospitals in Germany have contractually agreed to participate in the registry. During the first 15 months, data from over 2500 implants in over 2000 patients were registered in the DCIR. The work presented here describes the structuring, development, and successful establishment of the DCIR. Introduction of the DCIR represents an important milestone of future scientifically based quality control in CI care. The registry presented here can therefore be considered as an example for other areas of medical care and thus also sets an international standard.

Conception and implementation of a certification system for quality control of cochlear implant treatment in Germany

A standardized and structured process is indispensable for optimal hearing rehabilitation with cochlear implants (CI). The Executive Committee of the German Society of Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC), initiated the conception of a certification program and a Whitepaper based on the Association of the Scientific Medical Societies in Germany (AWMF) clinical practice guideline (CPG) describing the current medical standards of CI care in Germany. The goal was to independently confirm implementation of this CPG and make this information publicly available. With the support of an independent certification organization, successful implementation of the CI-CPG by a hospital would then be verified and confirmed by awarding the "Cochlear implant-provision institution" (Cochlea-Implantat-versorgende Einrichtung, CIVE) quality certificate. A structure for implementation of a certification system was developed based on the CI-CPG. The following steps were required: 1) conception of a quality control system for certification of hospitals working in accordance with the CI-CPG; 2) development of required structures for an independent review of quality-relevant structure, process, and result parameters; 3) development of a standard procedure for independent certification of hospitals; 4) development of a certificate and a logo to demonstrate successful certification; 5) practical implementation of the certification. Following design of the certification program and the required organizational structure, the certification system was successfully launched in 2021. Applications for the quality certificate could be formally submitted from September 2021. A total of 51 off-site evaluations were performed by December 2022. In the first 16 months from introduction, 47 hospitals were successfully certified as CIVE. In this period, 20 experts were trained as auditors, who have since then carried out 18 on-site audits in hospitals. In summary, the conceptual design, structure, and practical implementation of a certification program for quality control in CI care was successfully implemented in Germany.

[Conception and implementation of a certification system for quality control of cochlear implant treatment in Germany. German version]

A standardized and structured process is indispensable for optimal hearing rehabilitation with cochlear implants (CI). The Executive Committee of the German Society of Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC), initiated the conception of a certification system and a Whitepaper based on the Association of the Scientific Medical Societies in Germany (AWMF) clinical practice guideline (CPG) describing the current medical standards of CI care in Germany. The goal was to independently confirm implementation of this CPG and make this information publicly available. With the support of an independent certification organization, successful implementation of the CI-CPG by a hospital would then be verified and confirmed by awarding the "Cochlear implant-provision institution" (Cochlea-Implantat-versorgende Einrichtung, CIVE) quality certificate. A structure for implementation of a certification system was developed based on the CI-CPG. The following steps were required: 1) conception of a quality control system for certification of hospitals working in accordance with the CI-CPG; 2) development of required structures for an independent review of quality-relevant structure, process, and result parameters; 3) development of a standard procedure for independent certification of hospitals; 4) development of a certificate and a logo to demonstrate successful certification; 5) practical implementation of the certification. Following design of the certification system and the required organizational structure, the certification system was successfully launched in 2021. Applications for the quality certificate could be formally submitted from September 2021. A total of 51 off-site evaluations were performed by December 2022. In the first 16 months from introduction, 47 hospitals were successfully certified as CIVE. In this period, 20 experts were trained as auditors, who have since then carried out 18 on-site audits in hospitals. In summary, the conceptual design, structure, and practical implementation of a certification system for quality control in CI care was successfully implemented in Germany.

DNA methylation at an enhancer of the three prime repair exonuclease 2 gene (TREX2) is linked to gene expression and survival in laryngeal cancer

Background

Genetic aberrations in DNA repair genes are linked to cancer, but less is reported about epigenetic regulation of DNA repair and functional consequences. We investigated the intragenic methylation loss at the three prime repair exonuclease 2 (TREX2) locus in laryngeal (n = 256) and colorectal cancer cases (n = 95) and in pan-cancer data from The Cancer Genome Atlas (TCGA).

Results

Significant methylation loss at an intragenic site of TREX2 was a frequent trait in both patient cohorts (p = 0.016 and < 0.001, respectively) and in 15 out of 22 TCGA studies. Methylation loss correlated with immunohistochemically staining for TREX2 (p < 0.0001) in laryngeal tumors and improved overall survival of laryngeal cancer patients (p = 0.045). Chromatin immunoprecipitation, demethylation experiments, and reporter gene assays revealed that the region of methylation loss can function as a CCAAT/enhancer binding protein alpha (CEBPA)-responsive enhancer element regulating TREX2 expression.

Conclusions

The data highlight a regulatory role of TREX2 DNA methylation for gene expression which might affect incidence and survival of laryngeal cancer. Altered TREX2 protein levels in tumors may affect drug-induced DNA damage repair and provide new tailored therapies.

Electronic supplementary material

The online version of this article (10.1186/s13148-019-0666-5) contains supplementary material, which is available to authorized users.

[Paraneoplastic syndromes in ENT surgery]

Paraneoplastic syndromes are extremely rare in otolaryngology.However, they can significantly influence both the therapy and outcome of patients with oncologic disease. This report deals with two cases of paraneoplastic syndromes associated with malignant tumors of the head and neck region. A 45-year-old male presented with a polymyalgia rheumatica, which was identified as a synchronous feature of a hypopharyngeal carcinoma. The symptoms disappeared after successful surgical treatment of the carcinoma. No analogous report has been published as yet. As demonstrated in a second case of a 54-year-old male, leukocytosis can be paraneoplastically associated with a squamous cell carcinoma of the tongue. The international literature is reviewed in order to analyze the incidence of different paraneoplastic syndromes related to malignancies of the upper aerodigestive tract including the rare neuroendocrine oat cell carcinoma of the larynx.

Acoustically and electrically evoked responses of the human cortex before and after cochlear implantation

Multi-channel auditory evoked potentials (AEP) were recorded before and after cochlear implantation (CI) from a patient suffering from severe high frequency hearing loss with residual, but highly fluctuating hearing around 250 Hz. Immediately after CI activation early components of the N1 were present. Later N1 components developed during the use of CI. The unique result of this single case study is the concordance of the cortical AEP pattern obtained by native and artificial peripheral stimulation, which can be regarded as an indicator for the adequate function of the CI.

Assessment of rhinological parameters for evaluating the effects of airborne irritants to the nasal epithelium

OBJECTIVES

The initial contact area of inhaled toxins with the human body is the nasal mucosa. Upon irritation, nasal symptoms may occur that are well known as common viral infections of the airway and thus neglected by patients and physicians. Therefore, objective methods should be used to determine even minor irritative or inflammatory changes.

METHODS

Objective methods to assess changes in the nasal epithelium include endoscopy, rhinomanometry, acoustic rhinometry, anemometry, thermometry, laser Doppler flowmetry, measurements of mucociliary transport time and ciliary beat frequency, analysis of nasal secretions, nasal cytology, and subjective (UPSIT, CCCRC, Sniffin Sticks) and objective (electro-olfactogram, olfactory event related potentials) and olfaction tests.

RESULTS

Several different inhaled irritative and toxic substances, including metal dusts and steam, volatile organic substances, and inorganic gases, may harm the nasal epithelium.

CONCLUSIONS

The objective evaluation of nasal functions should be used to assess effects of airborne irritants. For patients complaining of toxic effects, early diagnosis is important in the prevention of severe damage to the upper and lower airways.

[Trauma of the Membranous Trachea Managed by the ENT-Surgeon]

BACKGROUND

Isolated perforations of the membranous trachea are extremely rare but potentially life-threatening complications of endotracheal intubations and minimally invasive tracheostomy techniques. Most of the case-reports have been written by thoracic surgeons or anesthesiologists but both the diagnostic procedures and the therapy are not standardized. The aim of this study was to evaluate the position of the ENT-surgery in the management of these lesions.

PATIENTS AND METHODS

Over a period of 6 years we treated 5 females, 3 males and 3 children with iatrogenic lacerations of the posterior tracheal wall. The lesions were complications of percutaneous tracheostomies or emergent intubations. The charts and videoprints of each patient were reviewed.

RESULTS

Clinical presentation was marked in all patients by the characteristical symptoms of paratracheal air leakage, i.e. pneumothorax, emphysema or airway obstruction. In 6 patients the onset of the symptoms occurred with a significant delay until to 2 days after the lesion was originated. Perforations were located at the distal third (8) and at the medial third (2) of the trachea or the subglottic area (1) and had a vertical shape with a length of 0.3-5.5 cm. Surgical repair using a transtracheal cervical approach or an endoscopical procedure was performed in 8 cases. 3 lesions having a length below 2 cm were treated nonoperatively. Outcome was excellent in all patients but a certain percentage of them claimed cough and dysphonia one or more years after the acute phase.

CONCLUSIONS

Because of their life-threatening character perforations of the membranous trachea must be diagnosed as soon as possible. However, the clinical presentation is not obvious in many cases. For the exact detection of the perforations rigid endoscopy is superior to flexible technique. The early surgical repair is recommended for the majority of the cases. Therefore, the transtracheal approach and endoscopical procedures are favorized. Moreover, these methods used routinely in ENT-surgery are also appropriate for lesions of the distal part of the membranous trachea and can be an alternative to the more invasive thoracotomy. Conservative treatment strategies should be limited to selected patients with small lacerations.

Presence of fluticasone propionate on human nasal mucosal surface and in human nasal tissue over a period of 24 h after intranasal application

BACKGROUND

Once-daily use of nasally applied glucocorticoids was demonstrated to be effective in the treatment of allergic rhinitis. The aim of the study was to measure concentrations of fluticasone propionate (FP) in nasal secretion and nasal tissue over a period of 1 day after a single application of 100 microg FP.

METHODS

Twenty-six patients applied nasal FP spray at different time intervals before surgery. Cotton swabs, used to clean the mucosal surface, and resected nasal tissue were extracted. FP concentrations were determined by RIA.

RESULTS

FP was found in nasal secretions in concentrations from 15 to 1 microg/g over a period of 20 h, and in nasal tissue in concentrations from 200 to 13 ng/g up to 24 h after the single application.

CONCLUSION

The long-persisting high concentrations of FP provide the pharmacokinetic basis for once-daily treatment.

[Diagnosis and treatment modalities in sinonasal inverted papillomas]

BACKGROUND

Today, etiology and pathogenesis of sinunasal inverted papillomas (IP) remain unknown. Surgical approaches and extension of surgical resections are still controversial.

PATIENTS AND METHODS

In a retrospective study we reviewed the charts of 90 patients with sinunasal IP. Using external (n = 78) or endonasal (n = 12) approaches the tumors were completely resected in all cases. 57 cases were investigated for human papilloma virus (HPV) by immunohistochemistry.

RESULTS

60% of IP extended beyond one single paranasal sinus or the nasal cavity. 7% infiltrated adjacent anatomical structures (subcutis, orbit, anterior skull base). The recurrence rate was 19% after a mean interval of 8.2 month. Associated malignancy was found in 7 cases (7.7%). HPV was detected in 9% of IP. Postoperative complaints were noticed by 27% of endonasal and 35% of trans-facial operated patients.

CONCLUSIONS

Because of the advanced tumor stage in the majority of cases, usually a radical trans-facial surgical excision of IP is required. Endonasal approaches are feasible in selected cases, but surgery has to be more extensive compared to surgery for sinunasal polyposis. In the literature and in our experience IP is rarely associated with carcinoma (10% in literature) and the incidence of malignancy is not increased in recurrent IP. Using PCR, the prevalence of HPV ranges from 7 to 69% in the literature. Our immunohistochemical results support a rather low prevalence of HPV in IP.

[Category loudness scaling to evaluate sound perception in cochlear and retro-cochlear lesions]

Category loudness scaling was used to investigate the loudness perception of 31 patients with a cochlear hearing loss (Group 1) by comparing the results with those found in 15 patients with retro-cochlear hearing loss caused by an acoustic neuroma (Group 2). Narrow-band noise signals at four different frequencies (0.5 to 4.0 kHz) were used. In the cochlear hearing-impaired subjects the slopes of the level-loudness functions tended to increase with increasing hearing loss, indicating positive recruitment, whereas the much shallower slopes associated with retro-cochlear lesions were presumed to reflect negative recruitment. The graphic representation of the iso-loudness functions revealed a different dynamic range between Group 1 and 2 with the ability to discriminate small differences of stimulus levels reduced in the presence of an acoustic neuroma. Category loudness scaling has been shown to be a valuable tool describing the individual perception of sound in a qualitative and quantitative manner. Furthermore, the method can be employed as an indicator of recruitment without any restrictive preconditions. For this reason the categorical loudness scaling can be a desirable method for supplementing the audiological diagnosis of a retro-cochlear hearing impairment through the frequency-specific description of a usable hearing-field and its dynamic range.

[Special characteristics of expert assessment of olfactory and taste disorders]

BACKGROUND

The number of medical expert opinions dealing with smell and taste disorders has continuously increased in recent years. However, an overview of the specific problems and results of those expert opinions has not been published until now.

INDIVIDUALS AND METHODS

Olfaction was assessed by multiple subjective tests in 145 individuals with chemosensory dysfunction caused by trauma or occupational and environmental exposures. Additionally, a gustatory test, nasal endoscopy, anterior rhinomanometry, and radiography of the paranasal sinuses were performed. Malignering was diagnosed on a trial of multiple symptoms. Retronasal olfaction was tested using the Güttich gustatory olfaction test.

RESULTS

Most of the medical expert opinions have been ordered by professional associations (42%) and insurance companies (28%). Compensation for olfactory dysfunction was claimed after trauma (64%), occupational exposure (23%) rhinosurgical procedures (8%), and laryngectomy (5%). Anosmia or hyposmia was claimed by 66% and 24% of all individuals, respectively. According to the results of the chemosensory tests, 41% of patients suffered from anosmia and 40% had hyposmia. Malignering was registered in 14%.

CONCLUSIONS

The study shows that the "characteristic case" is a male in the late fourties, complaining of anosmia initially noticed after an occipital or frontobasal head trauma. The assessment of olfactory deficits related to toxic or chemical occupational exposure is difficult when a latency between the occupational exposure and the onset of chemosensory dysfunction is present. Moreover, interactions between the occupational exposure and nicotine or alcohol abuse must be taken into consideration. Claims for medical liability arose in 3% of the study group after septoplasty and sinus surgery.

[Congenital laryngotracheo-esophageal cleft: diagnosis and surgical treatment by anterior, translaryngeal approach]

BACKGROUND

Laryngotracheoesophageal cleft is a rare but potentially life-threatening anomaly. Less than 200 cases have been published to date. Both the diagnostic and therapeutic recommendations are discussed controversially in the international literature.

PATIENT

We report on the diagnostic and surgical management of a type III cleft larynx in a one month old male presenting with aspiration, pneumonia, and aphonia. Hypoplasia of the cricoarytenoid muscles was associated to the cleft. Rigid endoscopy was found to be the best tool for the diagnostic exploration of the cleft, whereas flexible endoscopy failed to detect the defect. The cleft was broadly exposed using a modified anterior translaryngeal approach that included a tracheostomy. After debriding the mucosal margins, the defect was closed in two layers, and a t-shaped Montgomery tube was implanted. Two further revisions using the mentioned translaryngeal approach and one endoscopic procedure were necessary to achieve complete and permanent closure of the cleft.

RESULTS

Twenty months after birth the boy is able to swallow thick and liquid food without any problems. Stable scar tissue has grown within the former cleft region. The vocal cords are somewhat thickened but mobile in a reduced range. Both the trachea and the esophagus show quite normal diameters.

CONCLUSION

Considering the fact that the arytenoid cartilages touch or overlap each other a congenital defect within the posterior midline of the larynx can only be diagnosed by rigid endoscopy that spreads the cleft apart. In addition to our positive experiences with traumatic fistulas and stenosis of the juvenile trachea we recommend now the anterior vertical laryngeal incision for the operative management of the congenital type III cleft larynx. This direct open approach provides excellent exposure of all components of the defect without the risk of recurrent laryngeal nerve injury. Subglottic stenosis or impaired stability of the larynx described by other authors did not occur in this case. However, the postoperative period is relatively short and careful follow-up for a period of several years is therefore required.

[Nasal T-cell lymphoma as a differential diagnosis of the midline granuloma syndrome]

BACKGROUND

The lethal midline granuloma is a heterogeneous disorder and the pathogenesis is likely to be complex. Advances in immunocytochemical phenotyping and molecular genetics suggest that in several cases the origin have been proven to be malignant lymphomas, especially of T-cell lineage.

PATIENT

The present clinical and pathological cases of a 35-year-old woman shows how difficult it is to establish the precise diagnosis of lethal midline granuloma (LMG). The patient presented with recurrent infections of the paranasal sinuses. Later she developed infiltrates and ulcerous lesions of the nose, paranasal sinuses, and the base of the skull clinically consistent with a LMG. Immunohistologic studies using monoclonal antibodies led to the positive diagnosis of peripheral lymphoma of T-cells.

RESULTS

Several surgical interventions and explorations revealed a diffuse infiltration and partly necrotic lesions of the tissue. After identification of a T-cell lymphoma by histological examination, the patient received megavoltage irradiation of 45 Gy. Additional chemotherapy with alkylating agents was given. Two years after treatment the patient achieved and remained in remission.

CONCLUSION

The midline granuloma syndrome is a mutilating process produced by a number of diseases that progressively destroy the nose, paranasal sinuses and other regions of the midface. Infectious, neoplastic and idiopathic forms have been described. The specific diagnosis must be ascertained, as the treatment is different depending of the etiology of the disease. Sinonasal lymphomas constitute a important distinct clinicopathologic entity which may present as lethal midline granuloma. They seems to be strongly associated with Epstein-Barr virus. Aggressive therapy with radiotherapy and chemotherapy can stop the progress of the midfacial destruction. The correct treatment is still discussed controversially.

[Infection frequency and type of bacteria after tympanostomy tube drainage in childhood: gilded-silver tubes versus silicone tubes]

Otorrhea is the most common complication after tympanostomy tube insertions. In Germany there are currently two commonly used types of tympanostomy tubes: silicon tubes (ST) and gilded silver tubes (GT). Previously published in vitro studies by Tajima uncovered a positive correlation between the silicon concentration in culture fluid and the rate of growth of Staphylococcus aureus. Our study retrospectively evaluates the types of bacteria and rates of otorrhea after ST and GT insertions. The present study was undertaken to determine which of these tubes had a higher incidence of otorrhea and then whether silicon tubes stimulated the growth of certain types of bacteria, such as Staphylococcus aureus. In all, 186 ST and 59 GT were placed in 245 ears of 144 children. Both ST and GT were separated into three groups: first insertion of a tympanostomy tube, second implantation and insertion of a tympanostomy tube in an infected ear in the course of a mastoidectomy. No differences between ST and GT in causing otorrhea were found in the three groups. Nevertheless, ST in comparison to GT was associated with a higher incidence of infections with Pseudomonas aeruginosa. In contrast, a higher incidence of Staphylococcus aureus related to ST could not be proved. Twenty percent of the ears with mastoiditis were found to have Pseudomonas aeruginosa, but none of these ears implanted with a GT developed postoperative otorrhea. Our findings show that GT should be used when a ventilation tube is used during a mastoidectomy. Further, it is tenable to implant only GT because postoperative otorrhea in many cases is caused by insufficient water protection and water is frequently polluted with Pseudomonas aeruginosa.

[Aneurysmal hemorrhage as a complication of paracentesis]

Aneurysms of the temporal part of the carotid artery are unusually rare. The literature contains only a few previous reports dealing with hemorrhage from such malformations. In the present case massive bleeding occurred from a right-sided intrapetrous aneurym after myringotomy, which was performed as treatment for bilateral secretory otitis media. Due to the absence of any specific symptoms and the masking effect of middle ear glue preoperative identification of the aneurysm was not possible. Subsequent angiography showed the large fusiform extension of the intrapetrous aneurysm as well as multiple intracranial aneurysms. Leakage from the aneurism was closed definitively with muscle, fascia lata and a gelatin-resorcin-formalin-glue (Cardial). In order to apply the tissue patch the hypotympanic site of the aneurism was exposed using a posterior otosurgical approach. Due to extensive intracranial collateralization to the vertebral arteries bleeding persisted even after ligation of both carotid arteries. Temporary cardiac asystole was then induced to allow safe closure of the aneurysm. Following surgery the patient sustained loss of hearing in her ear and a partial peripheral facial palsy.

Olfactory function after functional endoscopic sinus surgery for chronic sinusitis

One hundred and fifteen patients suffering from chronic sinusitis were observed to analyse the prevalence of olfactory dysfunction and the influence of FESS. Pre-operative questionnaires were supplemented by examination of olfactory thresholds and discrimination. Pre-operatively, 58% of the collective were aware or complained of any olfactory deficit. However, the olfactory tests demonstrated that of the collective 52% were hyposmic and 31% anosmic. Eight per cent of the hyposmic patients presented with an isolated reduction of their ability to discriminate odours. Post-operative improvements were found in 70%. Normosmia was post-operatively achieved in 25% of the hyposmic patients, but only in 5% of the anosmic patients. Olfaction changed to the worse in 8% after FESS. Therefore, the prevalence of olfactory dysfunction in chronic sinusitis is pre-operatively higher, and the rate of improvement is lower than generally assumed. The extent of sinus disease as measured by the degree of intranasal polyposis correlates with olfactory dysfunction. Resections of the middle turbinate may have a negative effect on olfaction, due to damage to the olfactory fila or alteration of the normal aerodynamic pattern within the olfactory cleft. However, this hypothesis is based on a few observations and needs to be verified by further investigations.

[Pathophysiology of post-traumatic anosmia]

BACKGROUND

Head injury is one of the most common causes of olfactory disturbances. The incidence of posttraumatic anosmia depending from the severity of the injury lies between 5% and over 80%.

METHODS

Clinical assessments were performed in 26 cases with posttraumatic anosmia using subjective olfactometric tests. Additionally, morphological studies were performed in 26 other patients, who died between 36 hours and six weeks after head injuries.

RESULTS

Frontal basal injuries as well as minor occipital blows are capable of causing complete olfactory loss. About one-third of all patients were not aware of their chemosensory deficits, especially when associated neurological deficits occurred. Moreover, the studies show that: 1: The vulnerability of the fila olfactoria varies extremely and depends on unknown, highly individual parameters. 2: Trauma can induce local hemorrhage within the olfactory tracts and bulbs without any other intracranial lesions. 3: An intracerebral contusion is often misunderstood as the direct substrate of a posttraumatic anosmia. However, in a number of cases it is merely the sign of a strong injuring force, potentially capable of injuring the fila or the olfactory bulbus.

CONCLUSIONS

The findings indicate that the pathophysiology and biomechanics of posttraumatic anosmia should be the subject of critical discussion.

[Tumors in otorhinolaryngological surgery]

The most frequent tumors of the head and neck region are squamous cell carcinomas located within the oro- and hypopharynx [37%] or the larynx [36%]. They are clinically associated with chronic hoarseness dysphagia and swelling of the lateral neck. The general physician should pay attention to these initial symptoms, so that most of the tumors can be found noninvasively and at an early stage. Palpation and inspection are sensitive tools for the primary examination of many types of head and neck cancer. In addition, flexible or rigid endoscopy and high-resolution imaging are useful. Modern treatment of early head and neck cancer can be minimally invasive. The laser technique, new biocompatible implants for the reconstruction of postoperative defects and progress in radiotherapy complete the classic management of head and neck cancer.

[Quantitative evaluation of the Romberg test]

Simple and economical measuring platforms are available to aid the ENT clinician in examining vestibulospinal disorders. The aim of our study was to quantitatively interpret Romberg test measurements. Calculating the area between the zero line and the curves in sagittal and lateral direction--for the Romberg test with closed and open eyes--enables a quantification of body sway. For the evaluation of data, we developed a triangular diagram which allows a graphic representation and quantifies vestibulospinal reaction at a glance. We assessed a group of 80 persons without any symptoms of peripheral or central vestibular system disturbance. Selected patients complaining of vestibular disorders are helpful in demonstrating the objective and quantitative interpretation of the Romberg test, which is often analysed in a more subjective way.

[Traumatology of the facial skull in bicycle accidents]

About 15% of all traffic-related personal injuries involve bicycles. In 1989, 67,085 injuries involving bicyclists were registered in West Germany. The city of Münster is a particularly suitable site for studies of bicycle-related injuries because a high percentage of employees and students ride bicycles to work. The severity of bicycle injuries depends on the degree to which the head is traumatized. However, studies concerning trauma to the head in bicycle-related injuries are rare. The risk and the distribution of facial injuries in bicyclists is analyzed within the present study, which covers 78 patients with a total of 88 cranial fractures. The zygomatic and alveolar and orbital regions were most frequently fractured (35%), including 7% blow-out fractures. Thirty-three percent were fractures of the mandibular region, 12% of the bony nose. The soft tissue of the face was injured in 72% of all patients. Middle-aged male patients are more likely to suffer severe bicycle-related injuries. Bicyclists with a significant blood alcohol concentration are more likely to be involved in accidents that are their own fault. The results show that the helmets generally worn are not sufficient to prevent most facial injuries.

[Posturographic registration of body sway after odor stimulation]

The methods of "reflex olfactometry" are rarely able to detect simulated anosmia because of the lack of reproducible correlations between stimulus and intensity of reaction. Interactions between the olfactory and vestibulospinal systems have not yet been investigated. Thirty persons with normosmia and 21 patients with anosmia were studied using a posturographic platform. Only in subjects with normosmia were body sway increases statistically significant in an anterior-posterior direction after the application of an olfactory nerve stimulant. Stimulations of the trigeminal nerve cause both in subjects with normosmia, and anosmia an increase in body sway occurred in a sagittal and lateral direction. The recording of vestibulospinal reactions during platform posturography after application of an olfactory stimulations enables quantification of body sway. These responses can also be useful in differentiating real from stimulated anosmia.

[Sense of smell before and after endonasal surgery in chronic sinusitis with polyps]

Although olfactory dysfunction is a common clinical symptom in patients with chronic sinusitis, there are few written reports about the nature, frequency and therapeutic accessibility of the various dysosmias. We analysed pre- and postoperative olfactory function in 78 patients suffering from chronic sinusitis with nasal polyposis. Using a squeeze bottle technique we were able to detect preoperative hyposmia and/or dysfunction of olfactory discrimination in 40% and anosmia in 36%. Only 22% of these patients complained spontaneously of disabilities in smell. Endoscopic surgery improved hyposmias and anosmias in 71% and preoperative dysfunctions of olfactory discrimination in 61%. Postoperative thresholds for 2-phenylethanol and dimethyldisulfide worsened in 9% of all patients. Postoperative olfactory discrimination deteriorated in 11%. Preoperative and postoperative olfactory functions were not predictable in individual cases when nasal polyposis was limited. However, mechanical blockage of the nasal airway was just one of many other pathophysiological factors causing olfactory loss in patients with chronic sinusitis.

[Long-term results of lateral rhinotomy with medial maxillo-ethmoidectomy]

Functional and cosmetic results in 93 patients were analysed on average at 42 months after lateral rhinotomy and medial maxilloethmoidectomy. The rate of postoperative complications was 11.8%. The final cosmetic result was more than 1 year postoperatively satisfactory or better in 93.1% after osteoclastic and in 97.8% after osteoplastic lateral rhinotomy. 38.7% of the patients suffered from different postoperative complaints. The main problems were endonasal crusting, hypaesthesia in the V2 region, olfactory dysfunction and epiphora. Considering the results neither the rate of complications nor the cosmetic outcome are critical as usually mentioned in the literature. However, the rate of other different problems complained by the patients postoperatively give reason to add alternative oncosurgical procedures like midfacial degloving and endoscopic techniques, to the general operative repertoire of a hospital.

[Metastasis of benign pleomorphic adenoma]

A case of metastasing pleomorphic adenoma of the parotid gland, which was definitely benign, is reported. 11 years after the first operation of the tumour, which is suspected to have been removed insufficiently, there was a second local recurrence. In routine x-ray of the thorax the metastasis was seen peripherally in the thorax. Using DNA-Cytophotometry the benign character of both specimens could be confirmed. The fact that such a tumour can even produce metastases, proves its easy implantability. This leads to a critical discussion of each intervention, which is not definitive, including fine needle aspiration biopsy. There are only few indications for preoperative invasive interventions.

Tumors of the nasal cavity occurring after hypophysectomy

Olfactory neuroblastoma and malignant melanoma of the nasal cavities as second primary tumors after resection of pituitary adenomas in two patients are described. These cases, which seem to be the first documented in the literature, demonstrate the problems in diagnosis and treatment. Because of its rare occurrence, a second primary tumor may not be suspected when symptoms develop in the region of a previous hypophysectomy. A close follow-up after hypophysectomy for pituitary adenoma is recommended for the early detection of a second primary tumor. Pathogenetic considerations are discussed.

[Morphology and rhinologic importance of intumescentia septi nasi anterior]

The intumescentia septi nasi anterior is a protuberance on each side of the anterior part of the nasal septum containing "cavernous" tissue. None of the previous studies devoted to the general aspects of endonasal "cavernous" tissue refer to the incidence and rhinological function of the intumescentia. This investigation revealed an incidence of more than 80% in 170 individuals without any rhinological symptoms. The external morphology observed in 7 cadavers indicated a close topographical correlation of the position of the middle turbinate, the depth of the lateral nasal wall and the extension of the intumescentia. Histological examination showed a glandular mass interspersed with a dense vascular network similar to the "cavernous" tissue found within the lateral turbinates. Various filling conditions of the intumescentia have no significant influence on rhinomanometrical parameters and the quantity of nasal airflow. However, visualization of the endonasal flow within a nasal model containing the septal protuberance indicated that the intumescentia considerably alters the quality and local velocities of the endonasal airstream. Considering the results of the study, the intumescentia must be regarded as a completely normal formation of particular rhinophysiological importance, which, up until now, has not been mentioned in rhinosurgery.

[Clinical relevance of malignant lateral branchial cyst]

We analyzed 7 patients with so called "maligne lateral cervical cysts" regarding the controversies in the literature. Primary tumors of oropharyngeal sites were discovered in all these cases of "branchiogenic carcinoma" rising the final diagnosis of cystic metastases. Diagnostic tonsillectomy is supposed to be important to solve this problem of differential diagnosis. The issue of malignant transformation in cysts of branchial cleft origin has to be recognized as being an oncological artifact. We argue that the "maligne lateral cervical cyst" does'nt exist as a proper entity. In analogy to the principles of the treatment of oropharyngeal cancer ipsilateral neck dissection and wide local excision of the cyst followed by radiation therapy is the suggested plan of therapeutic management. Search for a possible unknown primary tumor within the oropharynx must be continued over years.

[Olfactory sensitivity in adenoid hyperplasia]

Olfactory sensitivity was assessed in 37 children aged between 5 and 12 years before and after adenectomy. Olfactory detection thresholds for 2-phenylethanol and dimethyldisulphide, as well as the ability to distinguish 8 other odours, were measured using a squeeze bottle test. The results suggest that preoperative olfactory detection thresholds in subjects with severe nasal obstruction attributable to adenoid hypertrophy are higher than in those with less severe nasal obstruction. The olfactory detection thresholds improved after adenectomy in cases with high preoperative nasal obstruction indices. The olfactory detection threshold remained relatively unchanged in cases with less severe adenoid hyperplasia. In contrast, improvement in olfactory discrimination was observed in all children, irrespective of the degree of preoperative nasal obstruction.

[Heat radiation--an essential factor of heat transport in caloric vestibular tests? Current experimental findings]

According to the accepted theory, in vestibular testing the caloric stimulus is transported from the auditory canal to the lateral semicircular canal by heat conduction via the bone. Some findings, however, are not consistent with this concept, e.g. the short latency of the vestibular response, and the fact that removing of the osseous bridge does not stop the transport of heat to the semicircular canal. Physically there are three modes of heat transport: conduction, convection, and radiation. So far, only the first two have been discussed with regard to vestibular calorization, however, they fail to explain the findings mentioned above. We carried out experiments on 10 cadaveric temporal bone specimens in order to evaluate the possible effect of heat radiation. With experimental conditions strictly regulated (specimens kept in climate box, 37 degrees C, saturated humidity, standardized irrigation of the auditory canal with 50 ml of water of 50 degrees C in 15 sec., temperature measured by thermistors at selected points of the specimen), the deviation in repeated experiments was within 0.1 degree C. In normal temporal bones a spreading of heat along the osseous structures was found in accordance with heat conduction via the bone. Then the bony bridge between posterior frame of the tympanic membrane and the lateral canal was removed along with the tegmen tympani, leaving the auditory canal and labyrinth connected only by a small anterior-inferior strut. The rise of temperature in the lateral canal, however, was not delayed and reduced, as expected, but faster and greater than in the original situation. If, now, a reflecting shield was inserted in the cleft between tympanic membrane and labyrinth the heat transfer was dramatically reduced. A similar effect could be achieved in the intact middle ear by a shield or by filling the cavity with gel. Convection as means of heat transport could be excluded. The experiments show that heat transport in the vestibular calorization is a complex process, which besides heat conduction involves radiation as an essential factor. This explains a number of experimental and clinical findings that, so far, had been unclear.

Transport of heat in caloric vestibular stimulation. Conduction, convection or radiation?

Experiments in temporal bone specimens were carried out under strictly controlled conditions: temperature (37 degrees C) and humidity kept constant; standardized irrigation of the external ear canal by an automated system (in 15 s, 50 ml of water, 11 degrees C above temperature of specimen), thermistor probes of 0.2 mm diameter placed in different parts of the specimens. In the intact temporal bone such an irrigation causes a rise in temperature with a gradient from the external ear canal across the bony bridge to the lateral semicircular canal as expected with heat conduction. After removal of the bony bridge, which is the main route for heat conduction, the rise in temperature in the lateral semicircular canal is greater and faster than in the intact specimen. This effect again is drastically reduced by placing a reflecting shield between tympanic membrane and labyrinth. In the intact middle ear inserting a reflecting shield or filling the cavity with gel also reduces the heat transfer to the labyrinth, although the bony routes for heat conduction are left untouched. The experiments prove that radiation plays an important part in heat transfer in caloric stimulation.

[Olfactory neuroblastoma--tumor entity or complex clinical picture?]

Clinical and radiological findings in seven cases of olfactory neuroblastoma are reviewed and discussed in the light of the international literature. The report provides further evidence of difficulties related to the predictability of the condition's clinical course, diagnosis, and therapeutic consequences. Moreover, the lack of uniform CCT and NMR features indicates that the discussion about the genesis, the biological action, the terminology, and therapy of these tumors has not yet reached a conclusion.