[The relevance of mirror examination in modern otorhinolaryngology]. / Relevansen af spejlundersøgelse i moderne otorhinolaryngologi.

INTRODUCTION: The aim of this study was to investigate whether the teaching of mirror examination of the larynx and rhinopharynx is still relevant and to estimate whether it is still a reliable examination. MATERIAL AND METHOD: Twenty-five patients underwent a mirror examination of the larynx and rhinopharynx by a young doctor, a young otorhinolaryngologist, and a senior otorhinolaryngologist. RESULTS: Not surprisingly the senior otorhinolaryngologist conducted the most adequate examinations. Forty-three percent of the laryngoscopies were adequate, that is all anatomic structures were seen. Forty-one per cent provided a reasonable survey, that is a few anatomic structures were not seen. This shows that 84% of the laryngoscopies could be used to give a reasonable examination of the larynx. Only 27% of the rhinoscopies were completely adequate, and as many as 49% were inadequate. DISCUSSION: Routine mirror examination of the larynx adequately provides a reliable diagnosis in most patients. But in some, it is not adequate, and here fibrolaryngoscopy is a good alternative and a more reliable examination. Mirror examination of the rhinopharynx is difficult, so if a disease of the rhinopharynx is suspected, the patient must be given a fibroscopy and biopsy under general anaesthesia.

[Surgical results of submandibular gland excision]. / Kirurgiske behandlingsresultater ved eksstirpation af glandula submandibularis.

INTRODUCTION: Extirpation of the submandibular gland is the standard treatment for benign disease in cases where conservative treatment fails. This study attempts a follow-up focusing on: the effectiveness of the treatment, the number of complications and the long-term complaints related to this surgical procedure. MATERIAL AND METHODS: This study included 110 patients who, due to benign disease, underwent submandibular gland excision at our hospital during 1989-1995. All the patients had their charts reviewed and were invited for a follow-up consultation, with an examination and an interview about complaints arising after the procedure. RESULTS: Average follow-up time was 7.2 years (range 3.3 to 9.4 years) and 72 patients (65.5%) reported back for follow-up. Sixty-eight of the examined patients (92%) reported relief from their preoperative symptoms. Forty-three patients (42%) had complications in connection with their surgery and fifteen patients (15%) needed a reoperation. The most frequent postoperative complaints were dryness of the mouth and reduced function of the marginal branch of the facial nerve. DISCUSSION: Most of the patients achieved relief of symptoms after surgery. There were a high number of complications, but most of these were of minor severity and temporary. The frequency of palsy in the submandibular branch decreased with time after operation while the frequency of oral dryness increased with time. Excision of the submandibular gland is an effective low-risk treatment for benign disease in the submandibular gland.

Prevalence of chronic otitis media in a randomly selected population from two communes in southern Vietnam.

The prevalence of chronic otitis media was studied in an urban and a rural community in southern Vietnam in 1995. A total of 3,300 children, aged from 6 months to 10 years, were selected randomly by taking every third child on the vaccination list. In this cross-sectional study, 453 ears were found to have chronic otitis media or sequelae otitidis, giving an overall prevalence of 6.86%. A total of 140 ears had perforations. Various attic changes were found in 73 ears and other chronic tympanic membrane changes, such as atrophy, tympanosclerosis and adhesions, in 219 ears. Cholesteatoma was seen in two ears.

Primary speech restoration at laryngectomy by insertion of voice prosthesis--10 years experience.

A total of 88 patients underwent laryngectomy at the ENT Department, Gentofte University Hospital, Hellerup, Denmark, from May 1989 to May 1999. Of these, 85 patients underwent salvage operations for squamous cell laryngeal carcinoma after previous full course radiotherapy. A total of 76 patients had primary tracheo-oesophageal puncture performed at the time of laryngectomy, 11 had a secondary procedure performed, 7 of these had been laryngectomized elsewhere. Eight patients were not eligible for tracheo-oesophageal puncture due to age, social reasons or extensive surgery. In all, 79 patients were able to use the prosthesis for communicative purposes weeks after the operation and developed fluent speech. During the observation time, 14 patients had their voice prosthesis removed or disconnected for various reasons. The average life duration for Provox voice prosthesis generation I vs Provox generation II was 3.1 and 2.3 months, respectively.

Surgical outcome in malignant parotid tumours.

Of 494 parotid gland tumours treated in Copenhagen county (population 600,000 inhabitants) in the period 1986-95, 50 patients (34 males, 16 females) had tumours that were proven to be malignant, making an incidence of 0.62/100,000/year. The patients age ranged from 14 to 87 years, mean 64 years. According to the UICC classification system, 6 tumours (12%) were classified as stage I, 23 (46%) as stage II, 14 (28%) as stage III, and 7 (14%) as stage IV. The material included 41 primary parotid gland tumours, histologically the tumours were verified as mucoepidermoid carcinoma (n = 13), adenocarcinoma (n = 9), squamous cell carcinoma (n = 6), carcinoma ex pleomorph adenoma (n = 3), acinic cell carcinoma (n = 3), adenoid cystic carcinoma (n = 3) and other histological diagnoses (n = 4). Primary malignant lymphoma of the parotid gland was diagnosed in six tumours and the last three tumours were metastatic carcinoma. Four therapeutic modalities were applied: surgery only, surgery + radiation, surgery + chemotherapy, and surgery + chemotherapy + radiation. Surgical radicality was achieved in 76% and radicality was unrelated to tumour histology. Normal or nearly normal facial nerve function (HB1&2) was noted at last follow-up in 60%. Five-year crude survival for all patients was 68%. Survival was not dependent on N-classification. Patients in stage I had a better survival than did patients in stages II, III and IV. No significant difference was observed in 5-year crude survival or in the post-operative facial nerve function between the radically operated patients (n = 38) and patients with residual tumour (p = 0.27, Log-rank test), (p = 0.48, chi 2 test).

Effect of photodynamic therapy on a heterotransplanted human parotid tumor.

To evaluate the effect of photodynamic therapy on human parotid tumors we used tumor specimens obtained from parotid surgery on a consecutive group of patients. The tumors were transplanted into a subcutaneous pocket of nude mice. The original human tumors were pleomorphic adenoma (four), adenolymphoma (one), acinic cell carcinoma (one), sarcoma (one) and low-grade adenocarcinoma (one). The most aggressive growth was seen in the low-grade adenocarcinoma. We re-implanted this tumor on ten mice bilaterally, and treated the tumors with photodynamic therapy (PDT), resulting in a mean depth of tumor necrosis of 5.4 mm (1-10 mm). In three cases we found vital tumor cells in the periphery of the tumor after treatment, with several new blood vessels in the surrounding tissue, indicating a great potential for neo-angiogenesis in this tumor. In order to evaluate the possible nerve damage subsequent to the photodynamic therapy, the ischiadic nerve in 24 lower limbs of nude mice were investigated. In one case only the macroscopical and histological investigation revealed signs of nerve damage. The current study demonstrates that the nude mice implantation model is excellent to investigate growth in both malignant and benign parotid tumors, and to test new therapeutic modalities. Photodynamic therapy seems to have a possible role in the future management of the malignant lesions of the parotid gland, in cases where radical surgery for some reason is not achievable.

[Treatment of malignant parotid tumors. Results from the county of Copenhagen]. / Behandling af maligne parotistumorer. Resultater fra københavns amt.

Out of 494 parotid gland tumours treated in Copenhagen county (population 600,000 inhabitants) in the period 1986 to 1995, 50 patients (tumours) were proven to be malignant, making an incidence of 0.62/100,000 per year. Age ranged between 14 and 87, mean 64 years. According to the UICC classification system, six tumours (12%) were classified as stage I, 23 (46%) as stage II, 14 (28%) as stage III and 7 (14%) in stage IV. Four therapeutic modalities were applied: surgery only, surgery + radiation, surgery + chemotherapy and surgery + chemotherapy + radiation. Surgical radicality was achieved in 76% and radicality was unrelated to tumour histology. Normal or nearly normal facial nerve function (HB1&2) was noted at last follow up in 60%. Five year crude survival for all patients were 68%. Survival was not depends on N-classification. Patients in stage I had a better survival compared to patients in stage II, III and IV. No statistically significant difference in five year crude survival between the radically operated patients (n = 38) and patients with residual tumour (p = 0.27, log rank-test), (p = 0.48 chi2-test was found.

Therapeutic approach to patients complaining of high blood pressure in a cardiological emergency room.

OBJECTIVE: To evaluate the management of patients complaining of high blood pressure (BP) in a cardiological emergency room. METHODS: Patients referred to the cardiological emergency room with the main complaint of high blood pressure were consecutively selected. The prescriptions and the choice of antihypertensive drugs were assessed. The classification of these patients as hypertensive emergencies or pseudoemergencies, according to the physician who provided initial care, was recorded. RESULTS: From a total of 858 patients presenting to the emergency room, 80 (9.3%) complained of high BP, and 61 (76.3%) received antihypertensive drugs. Sublingual nifedipine was the most commonly used drug (59%). One patient received intravenous medication, one patient was hospitalized and 6 patients (7.5%) were classified as hypertensive emergencies or pseudoemergencies. CONCLUSION: High BP could seldom be classified as a hypertensive emergency or pseudoemergency, even though it was a frequent complaint (9.3% of visits). Currently, the therapeutic approach is not recommended, even in specialized clinics.

[Intraoral cancer in the county of Copenhagen]. / Intraoral cancer i Københavns Amt.

A retrospective study of patients treated for intra-oral squamous cell carcinoma in Copenhagen county is reported. The material included 156 patients, 66 females and 90 males. Age at diagnosis varied between 35 and 95 years with a mean of 65 years. Mean age of females/males was 70/62 years. Twelve therapeutic modalities were performed; surgery, radiotherapy, chemotherapy and different combinations of these. Five year disease specific survival related to tumours' T-classification was 84% for T1, 35% for T2, 20% for T3 and 27% for T4. A statistically significant relation between the tumours' T-classification and the disease specific survival was noted (p < 0.00001). Five year disease specific survival related to N-classification was 62% for N0, 30% for N1, 25% for N2 and 0% for N3. Crude five year survival was 37% overall, 61% for patients in stage I, 32% for patients in stage II, 16% for patients in stage III and 17% for patients in stage IV. The results are similar to those achieved in other centres. Since no significant improvement has been noted in patient survival during the last five to six decades and since the therapeutic morbidity has not always been acceptable to the patients, other therapeutic principles, such as the so called minimal invasive therapy should be considered in future treatment of intra-oral cancer.

[Is the use of surgical microscope justified in thyroid surgery? 10-year experience with thyroid surgery performed by means of microsurgical technique]. / Har operationsmikroskopet sin berettigelse ved thyreoideakirurgi? Ti års erfaring med thyreoideakirurgi udført med mikrokirurgisk teknik.

Paralysis of the recurrent laryngeal nerve is the most disastrous complication following thyroid surgery. In order to minimize this complication, different devices have been used to identify the recurrent laryngeal nerve during surgery. The presently available devices are reviewed and we present our results with the device we used, the surgical microscope. Five hundred and seventy-three patients had thyroid surgery, 451 had benign lesions and 122 malignant. Calculated as nerves at risk, primary surgery in benign/malignant disease resulted in 0.6 per cent/3.5 per cent permanent paralysis and in recurrent and completion surgery this complication rate was 4.5 per cent/2.9 per cent. These results are pleasing but also stress that primary surgery should be radical so as to avoid completion or recurrent surgery.

[Oral ranula. A follow-up study]. / Mundbundsranula. En efterundersøgelse.

Ranula is a cystic swelling of the floor of the mouth, which is usually unilateral and relatively uncommon. The cyst arises from the sublingual salivary gland. We reviewed 14 patients operated in the period 1976-April 1998. There was no recurrence after marsupialization and after extirpation of the sublingual gland. Fourteen percent of the patients had recurrence after extirpation of the cyst. At the follow-up time (average 8.1 years) 18.2% had complications. We suggest that marsupialization/extirpation of the cyst should be primary treatment. In case of recurrence the sublingual gland should be extirpated.

[Benign neoplasms in the parotid gland in the county of Copenhagen 1986-1995]. / Benigne neoplasier i glandula parotis i Københavns Amt 1986-1995.

In a ten year period from 1986-95 433 patients were submitted to operation due to benign tumours in the parotid gland in Copenhagen County. In this study we made a retrospective analysis of the surgical outcome. The incidence was calculated to be 6.8 benign tumours in the parotid gland per 100,000 persons per year. The histological distribution showed a frequency of 54% pleomorphic adenomas, 28% adenolymphomas and 18% other tumours. In the observation period there was a 3% recurrence rate in our material, most frequently the pleomorphic adenoma. The risk of permanent damage to the facial nerve was 1% for severe injury and 3% for affection of the ramus marginalis. Frey's syndrome was present in 50% of the patients, moreover the syndrome was observed many years after surgery. The frequency rate reached its highest level about five years postoperatively.

Treatment of children with secretory otitis media (SOM) with amoxicillin and clavulanic acid (Spektramox) or penicillin-V (Primcillin). Bacteriological findings in the nasopharynx before and after treatment.

A total of 386 children, aged 1-10, with secretory otitis media for at least 3 months were randomly allocated to 2 or 4 weeks' treatment with penicillin-V (Primcillin) or amoxicillin + clavulanic acid (Spektramox). Spektramox was superior (p < 0.01) to Primcillin in eradicating Haemophilus influenzae and Branhamella catarrhalis from the nasopharynx. No difference was noted for Streptococcus pneumoniae and haemolytic streptococci, gr. A, B, C, G. No increase in the number of beta-lactamase-producing bacteria was noted after treatment. The nasopharynx was recolonized with the same bacteria within 4 weeks from cessation of treatment.

Microsurgical technique in thyroid surgery--a 10-year experience.

OBJECTIVE: To report the results of thyroid surgery in a University department of ENT--head and neck surgery, and to evaluate the benefits of the use of the surgical microscope in thyroid surgery. DESIGN: A retrospective evaluation of the records of all patients who underwent thyroid surgery in the 10-year period 1987-1996. METHODS: In addition to standard surgical principles the Zeiss multi-discipline universal surgical microscope with a 250 mm ocular lens was used in all cases. Total thyroidectomy was performed in all malignant cases, while unilateral lobectomy plus isthmus resection was the standard procedure in benign cases. PATIENTS: There were 573 patients, aged 11-87 years, 444 females and 129 males. Four hundred and fifty-one had benign lesions, 122 malignant. Four hundred and eighty-nine had primary surgery, 84 underwent completion surgery or surgery for recurrent disease. RESULTS: Primary thyroid gland surgery in benign/malignant disease resulted in permanent recurrent laryngeal nerve palsy in 0.6 per cent/3.5 per cent of the patients respectively, when calculated as nerves at risk (NAR). In benign recurrent or malignant completion surgery this complication rate was 4.5 per cent/2.9 per cent respectively. CONCLUSION: Thyroid surgery in our University ENT--Head and Neck Department with the use of the surgical microscope provides pleasing results, especially considering the diversity of surgeons, due to the departments' teaching responsibilities.

Problems in recruiting patients to controlled trials on children with secretory otitis media: a demographic comparison of excluded versus included patients.

One thousand one hundred and sixty-four patients formed the pool of patients from which we intended to recruit children to a controlled trial evaluating the efficacy of amoxicillin-clavulanate and penicillin-V in the treatment of secretory otitis media (SOM). Only 360 patients ended up to be evaluated, consisting only 30% of the primarily involved patients. The spontaneous improvement of the tympanometric condition was the major course of pre-trial dropouts. The demographic composition of included and excluded patients did not differ, as one might have expected. Very little has previously been published about this great number of excluded patients even though other authors must have had the same experience. It is concluded that a 3-month duration of SOM, evaluated by tympanometry by the investigators, is required as a minimum to qualify for entering a trial evaluating SOM.

Point prevalence of secretory otitis media in children in southern Vietnam.

Few reliable data exist on the prevalence of secretory otitis media (SOM) in the Third World. A large epidemiologic cross-sectional study was undertaken in two communes in southern Vietnam to study an urban and a rural community during two different climatic conditions: the dry and rainy seasons. The participants included 3,300 children (6,598 ears) ages 6 months to 10 years. Otolaryngological and medical histories were obtained, and an otolaryngological examination was carried out on 1,669 children in April 1995 (the dry season) and on 1,631 children in December 1995 (the rainy season). Tympanograms were obtained (n = 6,055), 429 of which were type B curves. The overall prevalence of SOM was 7.1%, the highest incidence was at the age of 2 years (with a prevalence of 22%), and there was a significantly higher prevalence of SOM during the rainy season than during the dry season. No significant difference in incidence was found in the urban district as compared to the rural district.

[Cervical necrotizing fasciitis]. / Cervikal nekrotiserende fasciitis.

Cervical necrotizing fasciitis is a rapidly progressive infection that involves the superficial and deep cervical fascia. Underestimation of this severe neck infection can delay diagnosis and treatment of this often fatal disease process. Three new cases, all with mediastinitis and fatal outcome are presented. Early diagnosis, aggressive surgical treatment and antibiotic therapy is essential if the high mortality rate is to be brought down in the future.

[Microsurgical laser treatment of Zenker's diverticulum. Economic aspects]. / Mikrokirurgisk laserbehandling af Zenkers divertikel. Okonomiske aspekter.

Zenker's diverticulum (hypopharyngeal/proximal oesophageal diverticulum/pouch) is a relatively uncommon cause of dysphagia usually in elderly patients. We describe the results of the first 10 patients operated for ZD with micro-endoscopic laserdiverticulotomy (LD), where the "spur" between the diverticulum and oesophagus is coagulated by means of a CO2 laser in our department. The results are compared with the results of the last nine patients operated with conventional diverticulectomy (DE) via incision on the neck. Two patients in the DE group had complications (wound infection and pneumonia), whereas no complications were seen in the LD group. An initially good result was seen in all the patients in both groups. Symptoms recurred in 11% in the DE group (one patient), whereas this was seen in 20% of the patients in the LD group (two patients). Re-operation of these two patients in the LD group relieved the patients of symptoms, but one patient was re-operated twice before this was achieved. Surgery time was reduced by 64%. Hospitalization time was shortened from a median of 16 (9-28) days with DE to 4 (0-9) days in the LD group. These factors represent a substantial economic saving by using LD as compared to DE. To be able to evaluate the result of LD roentgenographically, it has proven necessary to produce a pure lateral view of the diverticulum both pre- and post-operatively. The size and shape of the diverticulum is mostly seen as unchanged following surgery. With a pure lateral projection, it is however possible to see how the spur between the oesophagus and the diverticulum is diminished with resulting enhanced passage of contrast and practically no retention.

Antibiotic treatment of children with secretory otitis media. Amoxicillin-clavulanate is superior to penicillin V in a double-blind randomized study.

OBJECTIVE: To compare the effect of 2 different antimicrobial agents in the treatment of secretory otitis media (SOM). DESIGN: Prospective, double-blind, randomized study. PATIENTS: From a pool of 1450 children (aged 1-10 years) with SOM, defined by tympanometry as having type B or C2 tympanograms, 429 with SOM of at least 3 months' duration were included in the trial. After exclusion of 69 patients, the remaining 360 were evenly distributed among 4 treatment groups: penicillin V (Primcillin) for 14 and 28 days, and amoxicillin and clavulanate potassium in combination (Spektramox) for 14 and 28 days. Criteria for improvement was a change in tympanometric findings to type C1 or type A. RESULTS: The success rates were in favor of amoxicillin-clavulanate treatment for 28 days (P < .001) (rates for respective 14- and 28-day groups: penicillin V, 23% and 19%; amoxicillin-clavulanate, 31% and 44%). Antimicrobial therapy was more efficient (P < .001) in unilateral vs bilateral disease. CONCLUSION: Antibiotic treatment improves the middle ear status in patients with SOM, and amoxicillin-clavulanate provides superior improvement to penicillin V.

Squamous cell carcinoma of the oral cavity: the results of the surgical and non-surgical therapeutic modalities in a consecutive series of 156 patients treated in Copenhagen county.

A retrospective study on patients, treated for intraoral squamous cell carcinoma in Copenhagen county, is reported. The material included 156 patients, 66 females and 90 males. Age at diagnosis varied between 35 and 95 years with a mean of 65 years. Mean age of females/males was 70/62 years. Twelve therapeutic modalities were performed; surgery, radiotherapy, chemotherapy and different combinations of these. Three and five years crude survival were 43% and 37%. Three and five years crude survival rates were 70% and 61% for patients in stage I, 39% and 32% for patients in stage II, 29% and 16% for patients in stage III and 19% and 17% for patients in stage IV. The results are similar to those achieved in other centers. Since no significant improvement has been noted in patient survival during the last 5-6 decades and since the therapeutic morbidity has not always been acceptable to the patients, other therapeutic principles such as the so-called minimal invasive therapy should be considered in future treatment of intraoral cancer.