[Assessment of primary and secondary misallocations in the German Diagnosis Related Groups (G-DRG) system in otorhinolaryngology]

OBJECTIVE

Within the scope of a prospective study, the assessment reports completed in Otorhinolaryngology between March 1, 2011 and December 31, 2018 by the Health Advisory Boards in the German federal states of Lower Saxony and Bremen were analyzed regarding the primary and secondary misallocation in the G-DRG system.

METHODS

The assessment reports were documented using a standardized database system, which was developed on the basis of the electronic data interchange (EDI) by the Health Advisory Board in Lower Saxony. In addition, the documentation of medical assessment reports according to the G-DRG system was used for data analysis.

RESULTS

During the period from March 1, 2011 and December 31, 2018, a total of 42,126 cases of inpatient assessments of DRGs according to the G-DRG system were collected in the field of Otorhinolaryngology. In 1,946 cases, a primary and in 14,044 cases a secondary misallocation was detected. In 26,136 cases, neither a primary nor a secondary misallocation could be identified; thus, the rate of primary and secondary misallocations observed over the entire period was 5 % and 33 %, respectively.

CONCLUSIONS

Primary and secondary misallocations were most frequently found with treatments that included outpatient interventions in the catalog according to para. 115b of the German Social Code Fifth Book (SGB V). With secondary misallocations, exceeding the lower limit to length of stay (uGVD) therefore prevailed. In order to improve the demarcation between outpatient and (short-term) inpatient treatment in Otorhinolaryngology, in addition to the special consideration of the here presented "hit list" of Otorhinolaryngology departments, a more intensive cooperation between hospitals and the Health Advisory Boards of the federal states should be encouraged.

Begutachtung der Kodierung im German Diagnosis Related Groups System in der HNO-Heilkunde

Hintergrund Im Rahmen einer prospektiven Untersuchung wurden die im Zeitraum vom 01.03.2011 bis zum 31.03.2017 auf dem Gebiet der Hals-Nasen-Ohren-Heilkunde abgeschlossenen Begutachtungsaufträge im Geschäftsbereich GKV Krankenhaus der Medizinischen Dienste der Krankenversicherung Niedersachsen und im Lande Bremen hinsichtlich der Kodierung im G-DRG-System analysiert.

Material und Methoden Die Dokumentation der Behandlungsfälle erfolgte mit einem standardisierten Datenbanksystem, welches auf Basis des elektronischen Datenaustausches (DTA) vom MDK Niedersachsen entwickelt wurde. Ergänzend wurden die Unterlagen der durchgeführten Begutachtungen von Fallpauschalen nach dem G-DRG-System zur Beurteilung herangezogen. Weiterhin wurde die Begutachtung von einem Fall nochmals anhand der vorliegenden Begutachtungsunterlagen ausgewertet und exemplarisch ausführlich dargestellt.

Ergebnisse Im Zeitraum vom 01.03.2011 bis zum 31.03.2017 konnten im Fachgebiet HNO-Heilkunde insgesamt 27 424 Fälle von stationären Begutachtungen von Fallpauschalen nach dem G-DRG-System erhoben werden. In 7249 Fällen wurde nach der durchgeführten Begutachtung die dem Fall zugrundeliegende Fallpauschale verändert und in 20 175 Fällen war der Verdacht auf einen DRG-relevanten Kodierfehler in der Begutachtung nicht begründet; somit war über den gesamten Zeitraum eine DRG-Änderungsquote von 26% der Begutachtungen festzustellen.

Schlussfolgerungen Die fehlerhaften Kodierungen umfassten alle Arten von Kodierfehlern. Zur Verbesserung der Kodierqualität in der HNO-Heilkunde könnte neben der besonderen Berücksichtigung der vorgestellten „Hitliste“ durch die HNO-Abteilungen auch eine intensivere Zusammenarbeit zwischen den Krankenhäusern und den Medizinischen Diensten der Länder beitragen.

[False Medical Treatment Investigation in Otorhinolaryngology by the MDK in Lower Saxony and Bremen]

Objective: In a retrospective study the cases of possibly false medical treatment investigated by the Health Advisory Boards (MDK) in Lower Saxony and Bremen, Germany, in the years from 2012 to 2015 were analyzed. Material and Methods: All relevant data - especially diagnoses and procedures - were recorded in accordance to a standardized data entry form and were evaluated. In addition, relevant case studies are presented. Results: Altogether 206 cases of possibly false medical treatment were recorded for the investigated period. Among them there were 24 cases (12%), in which a false medical treatment was detected. The relevant case studies showed on the one hand, that relevant false medical treatment does occur in the field of ENT-surgery and on the other hand that it is sometimes very difficult do get the right decision even on a high-skilled background. Conclusions: In the field of Otorhinolaryngology there is a constant number of cases for examination in possibly false medical treatment, although the number of detection of false medical treatment is rather lower than in other disciplines. Analysis of possible false medical treatment cases produces the chance of preventing false medical treatment in future.

Diseases of the salivary glands in infants and adolescents

BACKGROUND

Diseases of the salivary glands are rare in infants and children (with the exception of diseases such as parotitis epidemica and cytomegaly) and the therapeutic regimen differs from that in adults. It is therefore all the more important to gain exact and extensive insight into general and special aspects of pathological changes of the salivary glands in these age groups. Etiology and pathogenesis of these entities is still not yet fully known for the age group in question so that general rules for treatment, based on clinical experience, cannot be given, particularly in view of the small number of cases of the different diseases. Swellings of the salivary glands may be caused by acute and chronic inflammatory processes, by autoimmune diseases, by duct translocation due to sialolithiasis, and by tumors of varying dignity. Clinical examination and diagnosis has also to differentiate between salivary gland cysts and inflammation or tumors.

CONCLUSION

Salivary gland diseases are rare in childhood and adolescence. Their pattern of incidence differs very much from that of adults. Acute and chronic sialadenitis not responding to conservative treatment requires an appropriate surgical approach. The rareness of salivary gland tumors is particularly true for the malignant parotid tumors which are more frequent in juvenile patients, a fact that has to be considered in diagnosis and therapy.

Reduction of Salivary Flow With Botulinum Toxin: Extended Report on 33 Patients with Drooling, Salivary Fistulas, and Sialadenitis

OBJECTIVES/HYPOTHESIS

The aim of the study was the evaluation of the clinical data of 33 patients who had had drooling attributable to various diseases, salivary fistulas, and sialadenitis and had been treated with injection of botulinum toxin type A (Botox). A controlled follow-up study documenting efficiency, possible side effects, and duration of the effect of treatment was also performed.

STUDY DESIGN

Retrospective clinical evaluation.

METHODS

Thirty-three patients with drooling attributable to head and neck carcinoma, neurodegenerative diseases, stroke, or idiopathic hypersalivation or with salivary fistula or chronic sialadenitis received injections of 20 to 65 U botulinum toxin type A into salivary glands under sonographic control. The entire salivary flow rate and the output per minute of the salivary analytes thiocyanate, total protein, alpha-amylase, acid phosphatase, kallikrein, and immunoglobulin A were measured at various times before and after injection. The patients were examined with regard to severity of their symptoms, including sonographic control investigation of their cephalic salivary glands.

RESULTS

Twenty-six patients (79% of all patients) reported a distinct improvement of their symptoms after toxin injection. Seven patients noted a return of high salivation rates and requested a second injection after 4 to 7 months. Duration of toxin effect varied widely among individuals. In general, salivary flow rates and thiocyanate output dropped sharply within 1 week after injection and had increased again after a period of 12 to 16 weeks. Conversely, amylase outputs increased during this period, whereas the outputs of the other analytes remained roughly constant. Sonography did not reveal any major changes in salivary gland parenchyma, and side effects were not noted.

CONCLUSION

Reduction of salivary flow in patients with drooling, salivary fistulas, or chronic sialadenitis by local injection of botulinum toxin type A into the salivary glands proved to be a dependable therapy for these disorders, as shown in the present extended report on 33 patients. Side effects were not observed. The effect of toxin application lasted for approximately 3 months. Based on their results, the authors recommend botulinum toxin injection as the therapy of choice in patients with the problem of drooling.

Improvement of chronic facial pain and facial dyskinesia with the help of botulinum toxin application

Background

Facial pain syndromes can be very heterogeneous and need individual diagnosis and treatment. This report describes an interesting case of facial pain associated with eczema and an isolated dyskinesia of the lower facial muscles following dental surgery. Different aspects of the pain, spasms and the eczema will be discussed.

Case presentation

In this patient, persistent intense pain arose in the lower part of her face following a dental operation. The patient also exhibited dyskinesia of her caudal mimic musculature that was triggered by specific movements. Several attempts at therapy had been unsuccessful. We performed local injections of botulinum toxin type A (BTX-A) into the affected region of the patient's face. Pain relief was immediate following each set of botulinum toxin injections. The follow up time amounts 62 weeks.

Conclusion

Botulinum toxin type A (BTX-A) can be a safe and effective therapy for certain forms of facial pain syndromes.

The role of botulinum toxin in the management of head and neck cancer patients

PURPOSE OF REVIEW

In this review article different relevant applications of botulinum toxin type A are demonstrated in patients with head and neck cancer.

RECENT FINDINGS

Patients with head and neck cancers of different etiologies often suffer from disorders concerning their musculature (for example, synkinesis in mimic muscles) or gland secretion in the head and neck region. This leads to many problems and reduces their quality of life. The application of botulinum toxin type A can improve movement disorders like synkinesis following reconstructive surgery in patients with cancers of the parotid gland, spasms of the pharyngo-esophageal musculature following laryngectomies and disorders of the autonomous nerve system like hypersalivation, hyperlacrimation and pathological sweating.

SUMMARY

The application of botulinum toxin type A is a helpful and minimally invasive treatment option in different functional disorders improving the quality of life in patients with head and neck cancers of different etiologies. Side effects are rare.

Tumors of the salivary glands in childhood and adolescence

PURPOSE

We report on 52 juvenile and adolescent patients with benign and malignant tumors of the salivary glands. Controlled follow-up was carried out to examine outcome and side effects of therapy.

PATIENTS AND METHODS

The clinical files of 52 patients were evaluated by computer-based methods. Follow-up was comprised of the findings of our clinic as well as those of the primarily consulted physicians and, if possible, up-to-date examinations in our clinic.

RESULTS

Benign tumors had their highest incidence in puberty and postpuberty. Forty patients (20 girls and 20 boys; 77%) had benign growths and 12 patients (9 girls and 3 boys; 23%) suffered from malignant neoplasms. After surgery for benign tumors we saw no postoperative recurrences in long-term follow-up. In the group of malignant tumors, 8 patients (66.7%) survived their disease in the long-term follow-up.

CONCLUSIONS

Salivary gland diseases are rare in childhood and adolescence. Their pattern of incidence differs very much from that of adults. This is particularly true for the malignant parotid tumors that are more frequent in juvenile patients, a fact that has to be considered in diagnosis and therapy.

Immunohistochemical investigations of the influence of botulinum toxin A on the immunoreactivity of nNOS in the parotid gland of the rat

PURPOSE

We wanted to prove the hypothesis that local injections of botulinum toxin A have an influence on the immunoreactivity of neuronal nitric oxide synthase (nNOS) in parotid glands of adult rats.

MATERIALS AND METHODS

Our group carried out immunohistochemical reaction of neuronal nitric oxide synthase (nNOS) in the parotid gland of female adult Wistar rats, in native (untreated) glands and after intraglandular injection of botulinum toxin A under general anesthesia. The immunoreactivity of nNOS was investigated on different times after injection.

RESULTS

Compared with the untreated glands, there was a significant decrease of nNOS in the treated organs that became stronger with extended toxin exposure time. After our laboratory in a pilot study had already shown in general a decrease of nNOS immunoreactivity after injection of botulinum toxin A into the cephalic salivary glands of the rat, the present study shows more explicit data on the effect of botulinum toxin A injection on a higher number of examined parotid glands and analyzes a time course of the effect duration.

CONCLUSIONS

In our study, it was shown that botulinum toxin A had an influence on the immunoreactivity of neuronal nitric oxide synthase (nNOS) in parotid glands. Participation of nitric oxide (NO) in the regulation of secretion from the parotid gland of the rat seems to be likely. It might be assumed that the influence of botulinum toxin A on nNOS in the parotid gland of the rat is able to explain the sometimes longer duration of toxin effect at the neuroglandular junction than at the motor endplate.

Inflammatory diseases of the salivary glands in infants and adolescents

OBJECTIVE

To determine retrospectively the localization, etiology and treatment of inflammatory diseases of the salivary glands in infants and children and to evaluate treatment outcome.

PATIENTS AND METHODS

Forty-five patients were treated in our institution in the period 1966-2000. The patients' records were evaluated and the results and side-effects of therapy were documented by a controlled follow-up study.

RESULTS

Twenty-five of our patients were females (55.6%) and 20 males (44.4%). Inflammatory disorders figured most prominently in the group of patients between 12 and 16 years (n=14). Inflammation of the submandibular glands was the most common disease with 53.3% (n=24). The most frequent underlying cause in this subgroup of acute and chronic sialadenitis was sialolithiasis of the submandibular gland (40%). All patients were symptom-free in the long-term follow-up and all were symptom-free after surgical intervention.

CONCLUSIONS

The present study shows that diseases of the salivary glands are rare among infants and children. Acute and chronic sialadenitis not responding to conservative treatment requires an appropriate surgical approach.

The effect of local injection of botulinum toxin A on the immunoreactivity of nNOS in the rat submandibular gland: an immunohistochemical study

PURPOSE

In our study, we intend to investigate the influence of local injections of botulinum toxin A on the activity of neuronal nitric oxide synthase (nNOS) in submandibular glands of adult rats. Since interest has been focused on the role of nitric oxide (NO) as a possible neuromodulator of secretory regulation processes in the upper aerodigestive tract, it was the aim of the present study to show that the toxin also interferes with the metabolic actions of NO on investigated rat submandibular glands. It is of great clinical interest whether the NO pathway is able to influence salivary gland secretion. Increasing of knowledge in this field maybe helpful to treat sialorrhoea, especially in juvenile otolaryngologic and neurologic patients.

MATERIALS AND METHODS

We performed immunohistochemical reaction of neuronal nitric oxide synthase (nNOS) in the submandibular gland of female adult Wistar rats, both in native (untreated) glands and after intraglandular injection of botulinum toxin A under general anesthesia. The immunoreactivity of nNOS was investigated on different times after injection.

RESULTS

Other than in the untreated glands, there was a significant decrease of nNOS in the treated organs, which became stronger with extended toxin exposure time. The present study shows explicit data on the effect of botulinum toxin A injection on a higher number of examined submandibular glands and is able to analyze a time course of the effect duration.

CONCLUSION

In our study, it was shown that botulinum toxin A had an influence on the immunoreactivity of neuronal nitric oxide synthase (nNOS) in submandibular glands. Therefore, the participation of nitric oxide (NO) in the regulation of secretion from these organs seems to be evident. It might be assumed that the influence of botulinum toxin A on nNOS in the submandibular gland of the rat is able to explain the sometimes longer duration of toxin effect at the neuroglandular junction than at the motor endplate.

Immunohistochemical evidence of nNOS and changes after intraglandular application of botulinum toxin A in cephalic salivary glands of adult rats

The purpose of our study was to investigate the possible influence of local injections of botulinum toxin A on the activity of neuronal nitric oxide synthase (nNOS) in cephalic salivary glands of adult rats. The role of nitric oxide (NO) as a possible neuromodulator of vascular regulation and in particular regulation of secretion in the upper respiratory and aerodigestive tract is discussed. We present immunohistochemical evidence of nNOS in the salivary glands of female adult Wistar rats, both in native (untreated) glands and after intraglandular injection of botulinum toxin A under general anesthesia. Other than in the untreated glands, there was a significant decrease in nNOS in the treated organs which became stronger with extended toxin exposure time. After our laboratory had already shown a decrease in acetylcholinesterase immunoreactivity after injection of botulinum toxin A into the cephalic salivary glands of the rat, the present study discusses a possible participation of NO in the regulation of secretion from these organs. As a conclusion, it might be assumed that the influence of botulinum toxin A on nNOS in the cephalic salivary glands of the rat is able to explain the sometimes longer duration of the toxin effect at the neuroglandular junction than at the motor endplate.

Up-to-date report of botulinum toxin therapy in patients with drooling caused by different etiologies

PURPOSE

In this study, we evaluated the clinical data for patients with drooling caused by various diseases, treated by injection of botulinum toxin A. We also present a controlled follow-up study documenting efficiency, possible adverse events, and duration of the effect of treatment.

PATIENTS AND METHODS

Thirteen patients with drooling caused by head and neck carcinoma, neurodegenerative diseases, or stroke received injections of 50 to 65 U botulinum toxin A (Botox; Allergan, Irvine, CA) in both submandibular and both parotid glands under sonographic control. We measured whole salivary flow rate and the salivary analytes of total protein, alpha-amylase, acid phosphatase, kallikrein, and immunoglobulin A at various times before and after injection. The patients were examined for severity of symptoms, including sonographic investigation of cephalic salivary glands.

RESULTS

All 13 patients reported a distinct improvement of their symptoms within 2 weeks after toxin injection. Three patients noted a return of high salivation rates after 12 weeks. Duration of toxin effect varied widely between individuals. In general, salivary flow rates dropped sharply within 1 week after injection but had risen again after 12 weeks. Conversely, analyte concentrations increased in the first stages of treatment and later decreased, returning to pretherapy levels. Sonography did not reveal any major changes of salivary gland parenchyma, and side effects were absent.

CONCLUSIONS

Local injection of botulinum toxin A into the salivary glands proved to be a dependable therapy for drooling caused by various etiologies, as shown in 13 patients. Adverse events were not seen. The effect of toxin application lasted for about 3 months. To further clarify this aspect, long-term studies are under way.

Successful management of drooling with botulinum toxin A in neurologically disabled children

OBJECTIVES

The present study investigates the effect of topical injections of botulinum toxin A into the cephalic salivary glands of children with chronic hypersalivation due to neurodegenerative diseases.

METHODS

Five children with hypersalivation due to severe neurological diseases received, under ultrasound guidance, a total of 50-65 units of botulinum toxin A (Botox) into the parotid and submandibular glands on both sides. All injections were tolerated without local anaesthesia. Before and 1, 2, 4, 8 and 12 weeks after toxin injection, salivary flow rates and the concentrations of total protein, alpha-amylase, acid phosphatase, kallikrein, and immunoglobulin A were measured in the secretions; simultaneously, the patients were clinically examined with regard to severity of symptoms, and their salivary glands were subjected to ultrasound study.

RESULTS

A distinct improvement of symptoms within the first 2 weeks following toxin administration were reported by the parents. Sialometry revealed considerably reduced flow rates but sialochemistry showed an increase of amylase activity. Ultrasound examination did not reveal any changes of the salivary parenchyma, and side-effects were absent.

CONCLUSION

Treatment of drooling by topical injection of botulinum toxin A into the salivary glands is a reliable and also side-effect-free therapeutic option for children with neurological disorders. All children involved in our study experienced a distinct improvement of their quality of life.

Botulinum toxin to reduce saliva flow: selected indications for ultrasound-guided toxin application into salivary glands

OBJECTIVES/HYPOTHESIS

The study investigates the effect of local injections of botulinum toxin type A (Botox) into the major salivary glands of the head in various states of hypersalivation. In particular, we studied pathological states with permanent as well as passing hypersalivation disorders and present new indications for local application of botulinum toxin to the salivary glands.

STUDY DESIGN

Retrospective clinical investigation.

METHODS

A total of 55 to 65 units of Botox were injected under sonographic control into the left and right parotid and submandibular glands of four patients with hypersalivation resulting from head and neck carcinoma, tracheostomy, and "idiopathic" hypersalivation disorder. At defined time intervals following injection, flow rate, total protein and immunoglobulin A content, and the enzymatic activities of amylase, acid phosphatase, and kallikrein were determined in the saliva. The patients were clinically examined to assess the severity of their symptoms, including sonographic control of the major salivary glands.

RESULTS

All four patients reported distinct improvement of their symptoms within 1 week after injection. Salivary flow rate had considerably dropped, whereas the concentrations of the salivary components were much increased. Sonography did not reveal any changes of the salivary gland parenchyma. Therapeutic side effects were absent.

CONCLUSIONS

Treatment of hypersalivation by local injections of Botox into the salivary glands of the head is a reliable and efficient therapy without side effects for certain otolaryngological diseases, especially if injections are performed under sonographic control. Extension of this therapeutic concept to other indications is suggested.

[Blocking secretion of exocrine glands in the head-neck area by administration of botulinum toxin A. Therapy of a rare disease picture]

BACKGROUND

Hypersecretion disorders of the exocrine glands of the head and neck area are a therapeutic problem in the field of otorhinolaryngology. In the present study, we demonstrate the effectiveness of local injections of botulinum toxin A to block secretions of exocrine glands of the head and neck area.

PATIENTS AND METHODS

Four patients suffering from hypersecretion disorders received local injections of botulinum toxin A. Two patients suffered from disorders of the salivary glands: one presented an idiopathic hypersialorrhea and another a salivary fistula after parotidectomy. A third patient suffered from epiphora and a further patient presented severe hyperhidrosis on the pilose head region. In a retrospective clinical study, the outcome of therapy was evaluated by clinical examination and chemical parameters.

RESULTS

Clear blocking of secretion in the treated glands could be demonstrated in all four cases. Possible side effects of the treatment could not be observed.

CONCLUSIONS

The present study was able to demonstrate a clear blocking of secretion of the exocrine glands of the head and neck region through botulinum toxin A, offering an improvement in therapy especially for the innovative indication of blocking the salivary glands of the head.

The effect of local injection of botulinum toxin A on the parotid gland of the rat: an immunohistochemical and morphometric study

PURPOSE

In this investigation, the effect of a local injection of botulinum toxin A on the concentration of acetylcholinesterase in the parotid gland of the rat was examined.

MATERIALS AND METHODS

After local injection into the parotid glands of female Wistar rats, the treated glands were excised, and immunohistochemical staining for acetylcholinesterase was performed. To discover possible changes in cell morphology after local application of botulinum toxin A, morphometric measurements also were performed on the excised parotid glands.

RESULTS

In contrast to the untreated, physiologic saline-injected, glands, there was a decrease in the concentration of acetylcholinesterase in the glands treated with botulinum toxin. No persistent changes in the number of acinar cells could be observed.

CONCLUSIONS

Because the cholinergic pathway of the autonomic nervous system has great importance in the secretion of fluid from the salivary glands, blocking this pathway and local application of botulinum toxin offers a possible therapeutic option for the treatment of hypersalivation in various otolaryngologic and neurologic diseases.

Gustatory sweating: clinical implications and etiologic aspects

PURPOSE

It was the aim of this study to provide detailed general information on the clinical picture of different kinds of gustatory sweating, including reevaluation of a series of patients who underwent parotidectomy, removal of the submandibular gland, or neck dissection.

PATIENTS AND METHODS

This study summarizes the statements of 548 patients questioned about the occurrence of gustatory sweating after parotidectomy (n = 296), extirpation of the submandibular gland (n = 79), and neck dissection (n = 173).

RESULTS

After parotidectomy, 45% of the patients had noticed gustatory sweating. In most of them (70%), the symptoms began within 6 months after surgery. Gustatory sweating developed in only one patient with submandibular extirpation (1.5%), and not at all after neck dissection. Most patients (52%) reported that the symptoms occurred independent of the kind of food ingested. These results show that the "masticatory component" is an important trigger for Frey's syndrome. Application of Minor's test localized gustatory sweating mainly in the region of previous parotid lobe removal, but also in other areas deriving their sensory supply from the auriculotemporal, greater auricular, and lesser occipital nerves. The size of the area affected by the sweating was similar after lateral and total parotidectomy. When evaluating clinical symptoms, subjective assessment by the patients seemed to play a major role. After submandibular extirpation and neck dissection, some patients reported gustatory sweating that was not verified by Minor's test.

CONCLUSION

There is general agreement that the cause of gustatory sweating is sympathetic or parasympathetic innervation of previously denervated sweat glands, initiated by gustatory triggers. The location of the "erroneous innervation" depends on the type of lesion. In cases after parotidectomy, misdirected parasympathetic regeneration is the model integrating all known factors into a rational concept. For didactic and systematic-pragmatic reasons, a clinically oriented classification of gustatory sweating (types I to III) seems to be useful.

Immunohistochemical and morphometric investigations of the influence of botulinum toxin on the submandibular gland of the rat

Immunohistochemical methods were used to study the effects of botulinum toxin A on the concentration of acetylcholinesterase in the submandibular gland of the rat. The toxin was injected into the glands of healthy adult female Wistar rats and immunohistochemistry performed on the excised organs. Morphometric measurements were also carried out to study changes of cell morphology after local applications of botulinum toxin A. Compared with untreated glands or glands injected with saline there was a decrease of acetylcholinesterase in the glands treated with botulinum toxin. As the cholinergic pathway of the autonomic nervous systems plays an important role in eliciting secretion from the salivary glands, inhibition of secretion by local application of botulinum toxin could be considered a therapeutic option for the treatment of various diseases affecting salivary gland function.

Clinical evaluation and surgical management of congenital preauricular fistulas

PURPOSE

The retrospective investigation evaluated the clinical data on patients with a preauricular fistula with respect to demographic factors, symptoms, preoperative diagnosis, and surgical therapy. Follow-up studies served to critically assess the outcome of the operations.

PATIENTS AND METHODS

The records of 62 patients were studied. Patients were divided into two groups: those operated on for the first time for a preauricular fistula and those operated on for a recurrence. Controlled follow-up was performed by means of a standardized questionnaire filled out by both the patients' physicians and the patients themselves.

RESULTS

The mean age of patients operated on for the first time was 16 years, and that of patients operated on for a recurrence was 22 years. Although the overall rate of recurrence was 21%, it differed widely between groups (14% in first operations and 42% in patients operated on for the first time for a recurrence). These figures are within the lower range of the recurrence rates previously reported. Serious side effects, such as persistent damage to the facial nerve, were not observed.

CONCLUSIONS

Operative management of a preauricular fistula is a treatment with few side effects that should be offered to each patient with such a malformation. Because the first operation is decisive for the further course of the condition, surgery should be performed under optimum conditions to avoid recurrence.

Extraglandular Warthin's tumours: clinical evaluation and long-term follow-up

Nine patients with extraglandular cystadenolymphoma (Warthin's tumour) were treated between 1965 and 1995 at the Department of Otorhinolaryngology, University of Göttingen. This number corresponds to 2.7% of all Warthin's tumours treated at our clinic so far. Although this rare tumour is well documented by case reports, a controlled follow-up study has not yet been published to the best of our knowledge. The retrospective investigation presented here gives the patients' clinical data and documents therapeutic success. Our results show the complete absence of recurrences after surgical excision of extraglandular cystadenolymphomas.

Surgical management of nonneoplastic diseases of the submandibular gland. A follow-up study

A total of 233 patients with nonneoplastic diseases of the submandibular gland were treated between 1966 and 1992 at the otorhinolaryngology department of the University of Göttingen. Of them, 212 patients (91%) suffered from sialadenitis with or without sialolithiasis, and 21 (9%) suffered from other diseases. The first part of the present study analyzes the clinical data with regard to history, symptoms, and therapy. It was found that in most cases (77%) extirpation of the affected gland had been the standard operation. In the second part, the surgical procedures applied are critically assessed. Extirpation of the submandibular gland proved to be an effective therapy in all patients. Side-effects were rare. The management of chronic sialadenitis caused by calculi should include extirpation of the submandibular gland. In case of calculi not causing inflammatory disease, lithotripsy should be considered.

Surgical management of benign tumors of the submandibular gland: a follow-up study

PURPOSE

This retrospective study evaluated data pertaining to history, symptoms, diagnosis, and mode of therapy of patients treated for benign tumors of the submandibular gland.

PATIENTS AND METHODS

The records of 38 patients were reviewed. The patients were divided into three groups: pleomorphic adenoma (first operation), pleomorphic adenoma (second operation for recurrence), and other tumors. Follow-up was done by questionnaires sent to the patient and referring doctor.

RESULTS

The vast majority of patients treated (92%) had had either a first or second operation for pleomorphic adenoma. Follow-up revealed that recurrence did not develop in the group of patients with primary surgery. However, one patient undergoing surgery for recurrent pleomorphic adenoma developed two recurrences. Two patients suffered from slight weakness of the lower lip.

CONCLUSION

Tumor recurrence was found only in the cases of second operation after previous surgery for pleomorphic adenoma. Therefore, the first operation should extirpate the entire gland to minimize the risk of recurrence.

[Exulcerating cystadenolymphoma of the parotid gland. A case report]

A recurrent adenolymphoma of the left parotid gland occurring in a 79-year-old woman is reported having caused an extensive ulceration of the epidermis, clinically suggestive of a malignant tumour. The ulcerative tumour process cannot be explained by a particular pattern of growth or a malignant transformation of the adenolymphoma. It is assumed that residual tumour cells of the initially incompletely removed adenolymphoma spread via a long-standing postoperative fistula to the epidermis leading to the uncommon ulceration.

Values and value--a vision for the Australian health care system

The Australian health care system is at a crossroads. Status quo is not a sustainable option for the future. Rising consumption, spiralling costs, the decline of private health insurance and a public sector 'bursting at the seams' threaten our traditional values of a universal, affordable, accessible, equitable, high-quality system. As a result, we believe that major reform of the health care system is both necessary and inevitable in order to ensure that the values of the system are maintained and to extract maximum value from limited health resources. In this article we lay out our vision for the Australian health care system. It is a vision characterised by transformational change--shifting of risk from patients and taxpayers to providers, downsizing of acute care capacity, integration of services across the system, rationalisation of State and Federal responsibilities and a 'shakeout' of providers and insurers resulting from intensified, but bounded, competition. We believe that the direction for health care players needs to be clarified so that, as a country, we can continue to have a best practice model of health care delivery. We present this vision as a 'stake in the ground' to set parameters around which this debate can emerge. It may be provocative and challenging, but it is our vision into the future.

Botulinum toxin treatment in patients with hemifacial spasm

Hemifacial spasm is nearly always a unilateral disease of the facial musculature and is characterized by involuntary tonic or clonic cramps that considerably reduce the affected patient's quality of life. In the past, a number of different conservative and operative therapeutic procedures have been applied for the treatment of hemifacial spasm. In many cases these attempts failed to control the disease permanently or resulted in unwanted, sometimes strong, side effects. We report our own experiences with botulinum therapy in 29 patients with hemifacial spasm (78 therapeutic sessions). In our patients the mean duration of an effect after treatment with botulinum toxin was 18.2 weeks. Side effects were rare. Our results since 1990 at the University of Göttingen demonstrate that subcutaneous application of toxin from Clostridium botulinum to involved facial muscles represents a reliable method for successful treatment of hemifacial spasm.