[Traumatology of the nose]

Isolated nasal bone fractures are the most common injuries of the central midface. They can be divided into different fracture types, depending on the exposure and orientation of violence. It is essential to ensure that there is no septal hematoma or abscess, which would require an emergency surgical intervention. A closed reposition can be offered if misalignment of the nose can still be observed after the edema swelling has gone down. In case of insufficient aesthetic and functional results, rhinoplasty/septal reconstruction can be performed 6 to 12 months after the trauma at the earliest. In children the, the decision for repositioning should be taken carefully in order to protect the nasal growing zone.

Influence of travel burden on tumor classification and survival of head and neck cancer patients

PURPOSE

Cancer patients have to overcome various barriers to obtain diagnostics and treatment at head and neck cancer centers. Travel distance to a specialized hospital may result in psychosocial and financial distress, thus interfering with diagnostics, treatment, and follow-up care. In this study, we have aimed to analyze the association of travel distance with cTNM status, UICC stage at primary diagnosis, and survival outcomes of head and neck cancer (HNC) patients.

METHODS

We have analyzed data of 1921 consecutive HNC patients diagnosed between 2014 and 2019 at the head and neck cancer center of the Comprehensive Cancer Center Ulm (CCCU), Germany. Postal code-based travel distance calculation in kilometers, TNM status, and UICC stage were recorded at initial diagnosis. The assembly of travel distance-related groups (short, intermediate, long-distance) has been investigated. Moreover, group-related survival and recurrence analysis have been performed.

RESULTS

In contrast to observations from overseas, no association of travel distance and higher cTNM status or UICC stage at primary diagnosis has been observed. Furthermore, no significant differences for recurrence-free survival and overall survival by travel distance were detected.

CONCLUSION

In southern Germany, travel distance to head and neck cancer centers seems to be tolerable. Travel burden is not synonymous with travel distance alone but also involves sociodemographic, monetary, and disease-specific aspects as well as accessibility to proper infrastructure of transport and health care system.

Infrasound a new weapon in cancer therapy?

BACKGROUND

Researchers take different positions when describing the effects of infrasound on the human body. Although several studies investigated the likely harmful effects of infrasound exposure from wind turbines a significant connection has not been found yet. There is evidence that infrasound interacts with cell metabolism and may disrupt cell membrane integrity.

OBJECTIVES

The suggested impairment of the cells' ultrastructure by infrasound leads to the question of whether infrasound can be therapeutically used, for instance in cancer therapy. This review provides the current state of the literature.

METHOD

Current literature on infrasound in cancer therapy including all studies with the search terms 'cancer' and 'infrasound' were identified and reviewed until the year 2020.

RESULTS

The present state of research reveals promising effects of targeted infrasound in cancer therapy. Infrasound directly affects the tumor cells' ultrastructure and seems to sensitize several types of cancer to chemotherapy, presumably due to membrane permeabilization. The application of infrasound on tumor cells without other therapeutic agents demonstrates different effects that probably depend on the type of cells, the applied frequency and sound pressure level as well as the time of exposure.

CONCLUSIONS

The mechanism of infrasound on cancer cells is not completely understood yet, hence, further studies have to be conducted to clarify the ultrastructural and metabolic changes inside the tumor cells. The development of suitable infrasound generators for the application in a clinical setting would be an important course of action.

Adenosine production in mesenchymal stromal cells in relation to their developmental status

BACKGROUND

Mesenchymal stromal cells (MSC) are multipotent progenitor cells found in the tumor microenvironment. They have an innate and regulatory immune activity, and they are able to produce immunosuppressive adenosine (ADO) via their ectonucleotidases CD39 and CD73. The present study explores ADO metabolism of MSC in relation to their developmental status.

METHODS

We analyzed MSC (n = 6), chondrogenic progenitor cells (CPC, n = 8), and chondrocytes (n = 8) for surface markers by flow cytometry. The ability to hydrolyze ATP and to produce ADO was tested by luminescence assays and mass spectrometry.

RESULTS

Significant differences in the surface marker expression of MSC, CPC, and chondrocytes were seen. While the expression of CD73 was observed to be the same on all cell types, the expression of the ectonucleotidase CD39 was significantly increased on MSC. Consequently, production of ADO was most abundant in MSC as compared with chondrocytes and CPC.

CONCLUSION

Mesenchymal stromal cells are potent producers of ADO and are, therefore, able to increase immunosuppression. As MSC differentiate into chondrocytes, they lose this ability and may take on other functions.

Age-related changes in T lymphocytes of patients with head and neck squamous cell carcinoma

Introduction

The number of aging cancer patients has increased continuously and will do so further in the future. The immune system of elderly people experiences critical changes over the time. Therefore, tumor-induced changes in the immune system are believed to differ in young and elderly cancer patients as well.

Methods

The effect of aging on the immune system was measured in peripheral blood lymphocytes (PBL) of healthy volunteers (n = 48, 21–84 yrs.) divided into three different age groups. Seventy years was set as a cut-off for defining subjects as elderly. Results were compared to two groups of adult cancer patients, which donated PBL and tumor infiltrating lymphocytes (TIL): young cancer patients (40–69 yrs.; blood: n = 13; TIL: n = 17) and elderly cancer patients (70–90 yrs.; blood: n = 20; TIL: n = 15) with head and neck squamous cell carcinoma (HNSCC). Frequencies and phenotypes of CD4⁺ and CD8⁺ T cells as well as regulatory T cells (T_reg) were assessed by flow cytometry.

Results

We observed lower frequencies of CD8⁺ cytotoxic T cells during aging in both groups. Frequencies of tumor infiltrating regulatory T cells were significantly higher than in the peripheral blood but showed a significant decline in older tumor patients. With increasing age, expression of immunosuppressive CD73 and CCR7 was lower and expression of PD1 elevated on peripheral T cells in healthy volunteers and tumor patients.

Conclusion

Immunosenescence takes place in healthy donors and cancer patients. Our results suggest that in elderly tumor patients, the immune system is impaired and the tumor-induced immune escape is less pronounced. The increased expression of PD1 implies the potential for effective immunotherapies in elderly, as treatment with checkpoint inhibitors could be more beneficial for elderly HNSCC patients.

Treatment-induced changes of lymphocyte subsets in patients with adenoid cystic carcinoma of the head and neck

PURPOSE

Adenoid cystic carcinoma (ACC) of the head and neck is a rare and highly malignant tumor, characterized by perineural growth and early distant metastases. The composition of immune cells in the peripheral blood and the tumor microenvironment is critical to tumor growth and control. However, little is known about the frequency and function of the relevant immune cell subsets in this entity.

METHODS

In ACC patients (n = 11) and matched healthy donors (n = 11), the frequency of peripheral blood T and B cells was measured by flow cytometry at different treatment stages of disease (24 samples). Cells were further characterized by their expression of CCR7, PD-1, CD39 and CD73. Tumor-infiltrating lymphocytes (TIL) were analyzed by immunohistochemistry for ten patients and for three patients by flow cytometry.

RESULTS

CD4⁺ T cells had significantly lower frequency after radiotherapy (RT). All other cell frequencies, including T_reg, were stable through course of the disease. In B cells, CD73 was reduced after RT. CCR7 expression on T and B cells in patients with relapse/metastases (R/M) differed significantly from patients with active disease. PD-1 remained stable. T_reg were more present in TIL compared to peripheral blood.

CONCLUSION

Composition of lymphocyte subgroups behaves similar to squamous cell carcinoma in the head and neck, except for T_reg, which remained stable. Nevertheless, the CD4⁺/T_reg ratio was lower after RT, which could stand for an immunosuppressive effect in these patients. Therefore, it could be beneficial treating ACC with combined RT and immunomodulatory drugs.

Mental distress and effort to engage an image-guided navigation system in the surgical training of endoscopic sinus surgery: a prospective, randomised clinical trial

The use of image-guided navigation systems in the training of FESS is discussed controversy. Many experienced sinus surgeons report a better spatial orientation and an improved situational awareness intraoperatively. But many fear that the navigation system could be a disadvantage in the surgical training because of a higher mental demand and a possible loss of surgical skills. This clinical field study investigates mental and physical demands during transnasal surgery with and without the aid of a navigation system at an early stage in FESS training. Thirty-two endonasal sinus surgeries done by eight different trainee surgeons were included. After randomization, one side of each patient was operated by use of a navigation system, the other side without. During the whole surgery, the surgeons were connected to a biofeedback device measuring the heart rate, the heart rate variability, the respiratory frequency and the masticator EMG. Stress situations could be identified by an increase of the heart rate frequency and a decrease of the heart rate variability. The mental workload during a FESS procedure is high compared to the baseline before and after surgery. The mental workload level when using the navigation did not significantly differ from the side without using the navigation. Residents with more than 30 FESS procedures already done, showed a slightly decreased mental workload when using the navigation. An additional workload shift toward the navigation system could not be observed in any surgeon. Remarkable other stressors could be identified during this study: the behavior of the supervisor or the use of the 45° endoscope, other colleagues or students entering the theatre, poor vision due to bleeding and the preoperative waiting when measuring the baseline. The mental load of young surgeons in FESS surgery is tremendous. The application of a navigation system did not cause a higher mental workload or distress. The device showed a positive effort to engage for the trainees with more than 30 FESS procedures done. In this subgroup it even leads to decreased mental workload.

Specific stressors in endonasal skull base surgery with and without navigation

The goal of modern organizational psychology is to recognize, anticipate and finally avoid stress situations. The aim of this study was to measure objectively the mental and physical demands during transnasal surgery with and without the aid of a navigation system. Forty endonasal surgeries (20 with and 20 without navigation, not blinded and not randomized) done by four different experienced rhinosurgeons (>250 FESS procedures done) were included. The heart rate, the heart rate variability, the respiratory frequency and the masseter tone were monitored as biometrical parameters by the surgeons during the whole surgery for the quantification of mental demand. Stress situations could be identified during the procedures by an increase in the heart rate and a decrease in the heart rate variability. Stress level in procedures with navigation did not significantly differ from procedures without navigation. Interestingly, in 10 % of the cases a navigation system would have been helpful, although the surgeon stated before the procedure that such a system would not be necessary. Other stressors could be identified like time pressure, students or colleagues speaking with the surgeon or chatting in the OR and system failure of medical devices, i.e. navigation, sinus drill, electrocautery or shaver. Surgical stressors blurred vision due to diffuse bleeding and drill out procedures in the sphenoid sinus. Calming situations were a quiet atmosphere in the OR (i.e. closed doors) and the participation of another experienced colleague, especially a neurosurgeon. Stress situations occur when complex medical devices like the navigation do not work. For their proper function it is important that the whole OR-team is trained with it. Unqualified or unmotivated OR personnel create stress for the surgeon and disharmony in the team, which then ends in inadequate behaviour.