[Comparison of 2 endoscopic surgery techniques for reliable therapy of Zenker diverticulum]. / Vergleich zweier endoskopischer Operationstechniken für eine sichere Therapie des Zenkerschen Divertikels.

BACKGROUND: A mediastinitis or intraoperative bleeding are the most feared complications of the transoral laser assisted diverticulotomy of Zenker's diverticulum. To reduce these complications we developed a new endoscopic surgical technique and compared the results of this new method with the results of patients who we treated earlier. PATIENTS AND METHODS: At the department of Otorhinolaryngology, Head and Neck Surgery, University of Luebeck 68 patients suffering from a hypopharyngeal diverticulum have been treated since 1987. In 64 patients we performed an endoscopic diverticulotomy using a CO2-Laser and the Weerda distending diverticuloscope. Four of the Zenker's diverticulua had to be removed by an external approach. From 1987 to 1994 a five millimeter bar between pouch and hypopharynx after diverticulotomy was left and sealed with fibrin glue in the first 38 patients. From 1995 to 1999 the spur of the hypopharyngeal pouch of the other 26 patients was completely separated. Afterwards we sutured the mucosa between the pouch and the hypopharynx to close the opened mediastinal space and sealed the former spur with fibrin glue. RESULTS: Comparing both endoscopic methods we had to observe concerning our first method one mediastinitis, a rise of body temperature in 29 patients (76%) and we had to perform a revision diverticulotomy in three patients (8%). Our modified technique didn't cause any mediastinitis, a rise of body temperature did only occur in five patients (18%) and no patient had to undergo revision surgery. CONCLUSIONS: The transoral complete separation of the spur of the hypopharyngeal pouch with suturing the mucosa of the pouch and the hypopharynx causes good functional results and means a further reduction of complications and a further improvement of the endoscopic diverticulotomy. Our new instruments (Fa. K. Storz, Tuttlingen) will be demonstrated.

[Esophageal scintigraphy of Zenker's diverticula before and after diverticulotomy]. / Osophagusszintigraphie von Zenkerschen Divertikeln vor und nach Divertikulotomie.

AIM: The filling and evacuation of Zenker's diverticula were scintigraphically examined before and after operation to quantify their functional relevance. These results were correlated with the symptoms of the patients and the findings of the barium swallow x-ray examination using cineradiography. METHODS: Sequential and static esophageal scintigraphies were performed in 17 patients with Zenker's diverticulum before and after laser surgical diverticulotomy. We used a gamma camera system in 45 degrees LAO-position after application of 15 ml of tea which was marked with 99mTc-DTPA. Filling and evacuation of the diverticulum were expressed in proportion to the administered activity. Relative volumes of the diverticula were obtained from cineradiography by using the height of the neighbouring cervical vertebra, and the clinical symptoms were divided into 4 groups. RESULTS: Zenker's diverticula could be verified visually and quantitatively by scintigraphy. The precise temporal course of the reduction of activity in the diverticulum was exactly determined. The scintigraphic retentions correlated with the x-ray volumes with a coefficient ranging from 0.55 to 0.85. Clinical symptoms also were not very closely related to scintigraphic and x-ray findings, respectively. CONCLUSION: The esophageal scintigraphy allows quantification of the filling and evacuation of Zenker's diverticula, thus it is suitable for objectivization of the functional relevance of the diverticula. That's why the esophageal scintigraphy should be taken to the diagnosis of diverticula in addition to the clinic and the x-ray examinations. The method is especially useful to evaluate the results after diverticulotomy.

Histopathology of laryngeal changes after long-term chondrosynthesis.

Two patients treated for laryngeal tumors at the University of Lübeck are presented. Both underwent laryngeal reconstructions with plate and screw fixation systems immediately following partial laryngectomies. Recurrent disease was found at 14 and 55 months, respectively, and was subsequently managed by total laryngectomy. The laryngectomy specimens with the plate and screws in situ were evaluated histopathologically, paying special attention to the reaction of local tissue to the implants. Findings showed that the metallic plates were fixed with screws in the bony trabeculae of the laryngeal skeleton. The histological response showed primary wound healing without evidence of sequestration or implant loosening, as often associated with excess mechanical stress. Furthermore, there were no signs of tissue necrosis or widespread chronic inflammation. In both patients, a small discrete area of chronic inflammation and soft tissue fibrosis was noted adjacent to the screw heads. This study supports our previously documented clinical experience that the use of chondrosynthetic techniques is almost complication-free and is an ideal system for performing precise anatomical reconstruction of the laryngeal skeleton.

Experimental and clinical evaluation of laryngeal chondrosynthesis.

The aim of this study was to investigate and develop techniques for stabilization and reconstruction of laryngeal defects with a method similar to osteosynthesis. In an anatomical study, 400 extrusion forces of sutures and various screws (Howmedica) were measured in the thyroid cartilage of fresh cadavers. A new screw was then especially designed for cartilage and a new technique was developed for stabilizing cartilage, using a screw-nut made out of bone. To date, 30 patients have undergone chondrosynthetic reconstruction of the larynx. Measurements of extrusion forces were found to depend on the degree of calcification present in the area of the laryngeal skeleton examined and the type of fixation device used. Good clinical results were achieved in all 30 patients studied and depended on stabilization of the two sides of the thyroid cartilage after thyrotomies, bridging of laryngeal defects and splinting of laryngeal fractures. Besides the increased extrusion forces the advantages of chondrosynthesis lay within the possibilities of axial stabilization and exact bridging of defects with or without implants.

[A new method of tongue reconstruction with neurovascular infrahyoid muscle-fascia flaps]. / Neue Methode der Zungenrekonstruktion mit neurovaskulären infrahyoidalen Muskelfaszienlappen.

Surgical treatment of tongue cancer can lead to extended defunctionalization, depending upon the size and localisation of the defect. Great problems of swallowing arise after total glossectomy or extensive resections of the base of the tongue even after reconstruction with myocutaneous island flaps or free flaps. We developed a neuromuscular island flap derived from the infrahyoidal musculature to reconstruct a total tongue or large defects of the tongue base. This fasciomuscular flap is formed by the M. sternothyroideus, M. sternohyoideus and the upper part of the M. omohyoideus. The axial blood supply arises from the A. thyroidea sup. The innervation is derived from the Ansa cervicalis N. hypoglossi. In case of total glossectomy we took this flap from both sides of the neck. With this new method we reconstructed total tongues after glossectomy in two patients and large defects of the tongue base in six patients. In the present paper the new surgical method and the functional results are described.

[Voice rehabilitation with the jejunum speech siphon: the biventer rein, a modification for prevention of aspiration]. / Die Stimmrehabilitation mit dem Jejunumsprechsiphon: Der Biventerzügel, eine Modifikation zur Vermeidung von Aspirationen.

The principle of operative voice rehabilitation after laryngectomy consists in forming a shunt between trachea and hypopharynx. The results of voice rehabilitation are generally good. Aspiration is the main disadvantage of this method, which negatively affects the quality of life. We modified the jejunum siphon of Ehrenberger and used this shunt operation mostly in total pharyngolaryngectomies. To avoid aspirations we formed a rein from both sides of the neck using the m. biventer. This rein hold the knee of the siphon and acts as a sphincter when the patient swallows, because the contractility of this muscle is preserved. We present this new method and compare the results of the first seven patients with those of the patients who were operated on without a rein from the m. biventer.

[Cervical lymph node metastasis as a primary manifestation of esthesioneuroblastoma]. / Zervikale Lymphknotenmetastasierung als Primärmanifestation eines Asthesioneuroblastoms.

A 51-year-old male patient presented with right-sided swelling of the neck and a 2-year history of decreasing olfaction that had culminated in complete anosmia. CT and MRI showed a calcified ethmoid tumor and destruction of the lamina cribrosa extending into the anterior fossa and frontal lobes. Contrast material demonstrated marked enhancement on the CT and MRI. Bilateral angiography of the external and internal carotid arteries failed to show tumor vascularity typical for an esthesioneuroblastoma but rendered an olfactory meningioma unlikely. Histological findings of cervical lymph nodes removed during neck dissection showed infiltration by an esthesioneuroblastoma (Kadish C classification). Tumor calcifications in these neoplasms are generally well seen on CT and--while not specific--may suggest the diagnosis. CT and MRI are the most sensitive methods of demonstrating local tumor growth, metastasis and bone destruction.

[Computerized tomography findings in neck abscess ]. / Computertomographischer Befund bei der Halsphlegmone.

Computed tomography was the diagnostic confirming method in two patients with a necrotic cervical phlegmon caused by an infection of streptococcus pyogenes and candida albicans. A cervical phlegmon is frequently caused by the lymphogenic transmission of diverse primary infections. The time between the primary infection and the appearance of a cervical phlegmon is very varied. In rare cases it is possible that the primary focus will have cured completely. The cervical fasciae separate the neck into three different spaces, which, together with their hypostatic abscess paths, can be visualized using CT. The use of the central veins (e.g., the jugular vein) to administer medication etc. means that the deep cervical phlegmone will continue to be a complication in intensive-care patients.

[Measures for reducing the rate of complications in endoscopic surgery of Zenker's diverticulum]. / Massnahmen zur Verringerung der Komplikationsrate bei der endoskopischen Operation des Zenkerschen Divertikels.

In the treatment of the pharyngeal pouch diverticulectomy and endoscopic diverticulotomy are generally accepted. The latter can lead to severe bleeding and mediastinitis. --Therefore the authors have extended the preoperative diagnostic procedure to include a DSA of the aortic arch. The simultaneous contrast filling of the pouch enables the exact position of the blood vessels relative to the bar to be established. --With the spreadable diverticuloscope developed by the authors, the use of a CO2 laser and an operating microscope, optimum endoscopic working conditions are assured. Postoperative sealing of the wound margin with fibrin reduces the likelihood of postoperative bleeding and mediastinitis, the risk of which have been further reduced by antibiotic prophylaxis and tube feeding for eight days. During and after the treatment of ten patients not a single complication has arisen.