[Prolonged ulcerative laryngitis]. / Prolongierte ulzerierende Laryngitis.

BACKGROUND: Prolonged ulcerative laryngitis is a rare, benign inflammatory alteration of the larynx that persists for months. The laryngoscopic findings suggest a malignant process and can therefore be a challenge for the treating ear, nose and throat (ENT) physician. OBJECTIVES: Presentation of the current database to provide an overview of the etiology, progress and treatment for everyday clinical practice. METHODS: Three case studies from the Department of Phoniatrics and Speech Pathology of the ENT Department, University Hospital Zurich, Switzerland, are presented. Analysis and discussion of the current literature base and of case reports in the English literature. RESULTS: The etiology and predisposing factors for this disease are unclear. Previous respiratory infection with cough and dysphonia seems to be the most common cause. Biopsies should be avoided. CONCLUSIONS: The typical laryngoscopic findings show corresponding circumscribed lancet-shaped ulcerations in the middle third of the vocal fold. The course of the disease appears to be self-limiting and without permanent structural consequences. Therefore, good patient education and close laryngoscopic follow-up should be performed.

[Current possibilities and challenges in the diagnosis of laryngopharyngeal reflux]. / Aktuelle Möglichkeiten und Herausforderungen bei der Diagnostik des laryngopharyngealen Refluxes.

Laryngopharyngeal reflux (LPR) is defined as backflow of gastral or gastroduodenal content into the upper aerodigestive tract and characterized by a variety of unspecific symptoms such as chronic cough, globus sensation, or mucus hypersecretion. Due to the lack of a gold standard and the heterogeneity of studies, the diagnosis of LPR is still problematic and challenging. However, in patients with characteristic symptoms and endoscopic findings, with an increased reflux symptom index, a pathologic reflux finding score (RFS), pathologic 24 h esophageal or oropharyngeal pH monitoring, and without any other underlying condition, the diagnosis of LPR is probable. In the following review, we critically discuss the abovementioned methods as well as more recent tools such as measurements of pepsin concentrations in the saliva for diagnosis of LPR.

[The German Sydney Swallow Questionnaire : Reliability and validity in patients with oropharyngeal dysphagia]. / Der deutsche Sydney Swallow Questionnaire : Reliabilität und Validität bei Patienten mit oropharyngealer Dysphagie.

BACKGROUND: The Sydney Swallow Questionnaire (SSQ) is a self-report inventory assessing subjective symptoms of oropharyngeal dysphagia with strong content, construct, discriminant, and predictive validity and test-retest reliability in a range of patient populations. OBJECTIVE: The main aim of this work was to assess the validity and reliability of the German version of the SSQ (SSQ-G). MATERIALS AND METHODS: In a cross-validation study, 48 adult German-speaking patients (12 women, 36 men) with neurogenic (n = 16), structural (n = 16), and functional (n = 16) oropharyngeal dysphagia were assessed with the SSQ­G and the MD Anderson Dysphagia Inventory (MDADI). Cronbach's α was applied to assess the reliability. Criteria and construct validity were investigated using the Spearman correlation coefficient. RESULTS: With Cronbach's α = 0.94, the internal consistency of the SSQ­G was excellent. The SSQ­G questions 1 and 17 showed a moderately significant and highly significant correlation coefficient of -0.43 and -0.45, respectively, with MDADI question 1 (p < 0.5, p < 0.001). Between questions 8, 11, and 12 of the SSQ­G and questions 7, 13, and 10 of the MDADI, coefficients of -0.48 to -0.55 showed a moderate to strong highly significant correlation (p < 0.001). Thus, the reliability and criterion and construct validity were statistically confirmed. CONCLUSION: The German version of the SSQ (SSQ-G) allows a reliable and valid assessment of functional swallowing difficulties. In combination with questionnaires on symptom-specific quality of life, such as the MDADI, a more differentiated clinical analysis of swallowing problems is thus possible.

Immediate Lip Trill Effects on the Standard Diagnostic Measures Voice Range Profile, Jitter, Maximum Phonation Time, and Dysphonia Severity Index.

OBJECTIVES: Semi-occluded vocal tract exercises are widely applied to improve vocal performance in speakers, singers, and voice patients. This study investigates immediate lip trill effects on standard voice assessment measures including voice range profiles, jitter, maximum phonation time, and Dysphonia Severity Index in vocally healthy women. STUDY DESIGN: Experimental study. SETTING: Otolaryngology clinic within tertiary hospital. SUBJECTS AND METHODS: Twenty-five vocally healthy women between 19 and 58 years (mean 38.4) were assessed before and after 3 minutes of standardized lip trill training combined with defined voice fundamental frequency and intensity modulations. Main outcome measures were fundamental frequency (F0) during counting (F0 counting), the singing voice range profile parameters minimum, maximum and range of F0 and voice sound pressure level (voice SPL), jitter (%), maximum phonation time (MPT), and the Dysphonia Severity Index (DSI). Wilcoxon signed rank test was applied to determine significant changes after exercise. RESULTS: After exercise the singing F0 and SPL range significantly increased from 549 (SD 217) to 612 (238) Hz and 45.1 (10.1) to 47.3 (9.8) dBA, resepctively (P<0.05). Maximum voice SPL significantly increased from 90.9 (10.3) to 94 (9.7) dBA (P<0.05). Mean F0 during counting showed a highly significant increase from 198 (SD 25.6) to 209 Hz (SD 25.4, P<0.01). No significant changes were found for all other parameters. CONCLUSIONS: In vocally healthy women, lip trill training immediately facilitates increases in mean F0 during counting, and singing F0 and SPL range. Future studies should investigate, if changes to these parameters indicate immediate responsiveness to voice exercise also in voice patients, and if these findings transfer to long-term effects through prolonged training.

[Pretesting of the German Vocal Fatigue Index (VFI-D)-transcultural translation and cross validation]. / Prätestung des deutschen Vocal Fatigue Index (VFI-D) ­ transkulturelle Übersetzung und Kreuzvalidierung.

BACKGROUND: In clinical routine, vocal fatigue is a common symptom in patients with dysphonia. OBJECTIVE: The aim of this study was to conduct a transcultural translation of the Vocal Fatigue Index (VFI), a standardized subjective questionnaire. Furthermore, pretesting and prevalidation were performed in 20 subjects, with comparison to the Voice Handicap Index (VHI­9i) and the Vocal Tract Discomfort Scale (VTD). MATERIALS AND METHODS: The translation, content review, and pretest of the German Vocal Fatigue Index (VFI-D) was divided into four sections: 1. transcultural translation, 2. expert voting on comprehensibility, 3. test of comprehensibility through cognitive interviews in 15 participants, 4. pretest of the VFI­D with cross validation compared to VHI­9i and VTD in 20 subjects. This process corresponds to current standards for transcultural translation and adaptation of questionnaires. RESULTS: According to expert voting and cognitive testing, the VFI­D is correct and comprehensible (intercoder reliability κ = 0.66). The factor analysis revealed three distinguishable parts: VFI­D part 1 correlates strongly with VHI­9i and VTD, VFI­D part 2 with VTD only (rho ≈ 0.800 each), and VFI­D part 3 correlates only weakly with VHI­9i and VTD (rho ≈ 0.585). Thus, convergence and divergence validity are proven. CONCLUSION: The first German version of the VFI­D might be a base for further research on symptoms, causes, and treatment options in vocal fatigue. Particularly patients in voice-intensive professions may benefit.

Indexed plasma drug concentrations for drug adherence screening in hypertensive patients.

AIM: Due to its high sensitivity, qualitative plasma drug screening by liquid chromatography/tandem mass spectrometry may not be able to distinguish same-day drug intake from drug use on preceding days and cause misclassifications of drug adherence in hypertensive patients. Analysis of plasma drug concentrations may provide more accurate results. PATIENTS AND METHODS: We describe dose-dependent indexing of plasma drug concentrations for expected peak concentrations to define individual screening thresholds for same-day drug use. To explore its utility, plasma samples from 9 hypertensive patients without major comorbidity were prospectively analyzed on two occasions. All were on hydrochlorothiazide with either amlodipine (n=7) and/or valsartan (n=6) at different doses. Drugs were quantitated by mass spectrometry. Non-adherence was defined if an indexed drug concentration was below the expected trough level at 24-hour dosing interval. RESULTS: All patients were adherent by qualitative plasma screening (spectrometric sensitivity). On the first visit (random sampling time), mean plasma concentrations of the drugs were 102±70, 15.4±6.7 and 2529±1608ng/mL, and mean indexes 84±57%, 85±35% and 60±38%, respectively. Using the study criterion, non-adherence was suspected in three. Intraindividual cross-checking retained two. On the second visit (fixed sampling time), amlodipine concentration was 15.6±8.5ng/mL (88±52% after indexing). Two patients were non-adherent according to the study criterion. CONCLUSION: Indexing of plasma drug concentrations appears practicable and useful for drug adherence screening under clinical conditions. With this technique, same-day drug intake can be easily distinguished which reduces the risk of false positive results associated with qualitative drug screening.

Acoustic Perturbation Measures Improve with Increasing Vocal Intensity in Individuals With and Without Voice Disorders.

OBJECTIVE: In vocally healthy children and adults, speaking voice loudness differences can significantly confound acoustic perturbation measurements. This study examines the effects of voice sound pressure level (SPL) on jitter, shimmer, and harmonics-to-noise ratio (HNR) in adults with voice disorders and a control group with normal vocal status. STUDY DESIGN: This is a matched case-control study. METHODS: We assessed 58 adult female voice patients matched according to approximate age and occupation with 58 vocally healthy women. Diagnoses included vocal fold nodules (n = 39, 67.2%), polyps (n = 5, 8.6%), and muscle tension dysphonia (n = 14, 24.1%). All participants sustained the vowel /a/ at soft, comfortable, and loud phonation levels. Acoustic voice SPL, jitter, shimmer, and HNR were computed using Praat. The effects of loudness condition, voice SPL, pathology, differential diagnosis, age, and professional voice use level on acoustic perturbation measures were assessed using linear mixed models and Wilcoxon signed rank tests. RESULTS: In both patient and normative control groups, increasing voice SPL correlated significantly (P < 0.001) with decreased jitter and shimmer, and increased HNR. Voice pathology and differential diagnosis were not linked to systematically higher jitter and shimmer. HNR levels, however, were statistically higher in the patient group than in the control group at comfortable phonation levels. Professional voice use level had a significant effect (P < 0.05) on jitter, shimmer, and HNR. CONCLUSIONS: The clinical value of acoustic jitter, shimmer, and HNR may be limited if speaking voice SPL and professional voice use level effects are not controlled for. Future studies are warranted to investigate whether perturbation measures are useful clinical outcome metrics when controlling for these effects.

[Prevalence of carotid artery stenosis in nonagenarians: Survey in a primary care hospital]. / Prévalence d'une sténose carotidienne chez le nonagénaire : résultats d'une enquête hospitalière.

AIM: Carotid artery stenosis increases with age and may cause brain ischemia if arterial hypotension occurs. We performed a monocentric pilot study to investigate its prevalence in the very elderly and to assess its potential influence on blood pressure (BP) goals during antihypertensive treatment. METHODS: All patients≥90 years of a primary care medical ward were prospectively included over 15 months. Ultrasound exams of the precerebral arteries were offered to all elderly patients for routine evaluation of their cardiovascular risk. Frequencies of stenosed common, internal and external carotid arteries (CCA, ICA, ECA) were analyzed together with clinical BP and antihypertensive therapy. Patients with circulatory shock and readmissions were excluded. RESULTS: Sixty-three patients aged 92±3 years (78% female) hospitalized for a median of 11 days were included. On admission, 76% were on antihypertensive drugs vs. 86% at discharge. Mean admission BP was 149/77 vs. 129/72mmHg at discharge; systolic BP<140mmHg 36% vs 64% (P<0.05). Mean intima-media thickness (ACC, right/left) was 8.7/9.4mm. Prevalence of plaque or stenosis<60% was: CCA 19.0%, ICA 19.0%, ECA 31.7%, bulb 74.6%; of stenosis≥60%: CCA 0%, ICA 7.9%, ECA 19.0%, ICA bilateral 1.6% (unilateral occlusion 3.1%, no bilateral). Coincidence of systolic BP<120mmHg and ACI stenosis≥60% had a probability of 1-2%. CONCLUSION: Concerning the risk of brain ischemia due to carotid artery stenosis, a BP goal<140mmHg should be safe for most nonagenarians. If individual BP goals are lower, searching for significant stenosis by ultrasound may be useful.

[Autonomic angiotensinergic fibres in the human heart with an efferent sympathetic cophenotype]. / Le cophénotype sympathique efférent des fibres autonomes angiotensinergiques dans le cœur humain.

AIM: The autonomic innervation of the heart consists of sympathetic and parasympathetic nerve fibres, and fibres of the intrinsic ganglionated plexus with noradrenaline and acytylcholine as principal neurotransmitters. The fibres co-release neuropeptides to modulate intracardiac neurotransmission by specific presynaptic and postsynaptic receptors. The coexpression of angiotensin II in sympathetic fibres of the human heart and its role are not known so far. METHODS: Autopsy specimens of human hearts were studied (n=3; ventricles). Using immunocytological methods, cryostat sections were stained by a murine monoclonal antibody (4B3) directed against angiotensin II and co-stained by polyclonal antibodies against tyrosine hydroxylase, a catecholaminergic marker. Visualisation of the antibodies was by confocal light microscopy or laser scanning microscopy. RESULTS: Angiotensin II-positive autonomic fibres with and without a catecholaminergic cophenotype (hydroxylase-positive) were found in all parts of the human ventricles. In the epicardium, the fibres were grouped in larger bundles of up to 100 and more fibres. They followed the preformed anatomic septa and epicardial vessels towards the myocardium and endocardium where the bundles dissolved and the individual fibres spread between myocytes and within the endocardium. Generally, angiotensinergic fibres showed no synaptic enlargements or only a few if they were also catecholaminergic. The exclusively catechalominergic fibres were characterised by multiple beaded synapses. CONCLUSION: The autonomic innervation of the human heart contains angiotensinergic fibres with a sympathetic efferent phenotype and exclusively angiotensinergic fibers representing probably afferents. Angiotensinergic neurotransmission may modulate intracardiac sympathetic and parasympathetic activity and thereby influence cardiac and circulatory function.

[Variability of plasma angiotensinogen levels and risk of hypertension in a transgenic rat model]. / Variabilité des concentrations plasmatiques de l'angiotensinogène et risque d'hypertension artérielle chez le rat transgénique.

AIM: Genetic polymorphisms of the human angiotensinogen gene are frequent and may induce up to 30% increase of plasma angiotensinogen concentrations with a blood pressure increase of up to 5mmHg. Their role for the pathogenesis of human arterial hypertension remains unclear. High plasma angiotensinogen levels could increase the sensitivity to other blood pressure stressors. METHODS: Male transgenic rats with a 9-fold increase of plasma angiotensinogen concentrations and male non-transgenic rats aged 10 weeks were treated or not with NG-Nitro-L-arginine-methyl ester for 3 weeks in their drinking water (n=3/group). Systolic blood pressure and body weight were measured at baseline and at the end of the study when left ventricular weight and ventricular expression of angiotensin I-converting enzyme and procollagen Iα1 were determined (polymerase chain reaction). RESULTS: At baseline, transgenic rats had +18mmHg higher bood pressure and -8% lower body weight compared to non-transgenic rats (P<0.05) without significant changes for the vehicle groups throughout the study (P>0.05). NG-Nitro-L-arginine-methyl ester increased blood pressure, left ventricular weight and left ventricular weight indexed for body weight by +41%, +17.6% and +18.6% (P<0.05) in transgenic and +25%, +5.3% and +6.7% (P>0.05) in non-transgenic rats compared to untreated animals, respectively. Cardiac gene expression showed no differences between groups (P>0.05). CONCLUSION: Increased plasma angiotensinogen levels may sensitize to additional blood pressure stressors. Our preliminary results point towards an independent role of angiotensinogen in the pathogenesis of human hypertension and associated end-organ damage.

[Unilateral renal denervation and the renal kallikrein-bradykinin system in the rat]. / La dénervation rénale unilatérale et le système kallikréine-bradykinine rénal chez le rat.

AIM: The antihypertensive effect of renal denervation in hypertensive patients is partially explained by increased tubular natriuresis. To study the possible contribution of the kallikrein-kinin system (KKS) to this natriuretic effect in rats, we measured kallikrein activity (KA) and bradykinin concentrations (BK) in plasma and tissues. METHODS: To measure KA, we adapted and validated an enzymatic assay that cleaves para-nitroaniline (pNA) from the tripeptide H-D-Pro-Phe-Arg-pNA. The coefficients of variation (CV) within- and between-assays were less than 8% for plasma and tissue KA (plasma n=6 and 13; tissue n=4). Linear results for serially diluted samples confirmed the assay specificity. Tissue BK determinations were based on an established assay for plasma BK: tissue was homogenized and kinins extracted in ethanol, and BK was isolated by high-performance (HPLC) liquid chromatography and quantitated by radioimmunassay. Within- and between-assay CV for plasma BK were 18% (n=8 and n=35, respectively) and for BK in various tissues less than 16% (n=5-8). RESULTS: In male Wistar rats (n=3), plasma BK was 8.2 ± 6.6 fmol/mL (mean ± SD), and tissue BK (fmol/g) in 14 tested organs varied between brain (14 ± 3) and submaxillary gland (521 ± 315). Six days after left-sided unilateral renal denervation, left renal tissue BK (89 ± 9) was not different from right renal BK (75 ± 23). Similarly, KA was comparable in the two kidneys (left 18.0 ± 1.5, right 15.8 ± 1.4 µkat/g). CONCLUSION: Any possible effect of unilateral renal denervation on the kidney's KKS would have to be bilateral.

[Diagnostic and therapeutic pitfalls in benign vocal fold diseases]. / Fehler und Gefahren: Behandlung gutartiger Kehlkopferkrankungen.

More than half of patients who present with the symptom of hoarseness show benign vocal fold changes. The clinician should be familiar with modern diagnostic and therapeutic possibilities of benign vocal fold changes in order to ensure an optimal and individualized attention to voice patients. Basic knowledge of the etiology are provided for targeted phonosurgical or conservative therapy. This review article focuses on the diagnostic and therapeutic limitations and difficulties of treatment of benign vocal fold tumors, the management and prophylaxis of scarred vocal fold changes and the issue of unilateral vocal fold paralysis.

[A new gene locus for an autosomal-dominant non-syndromic hearing impairment (DFNA 33) is situated on chromosome 13q34-qter]. / Ein neuer Genort für eine autosomal-dominante, nichtsyndromale Schwerhörigkeit (DFNA33) liegt auf Chromosom 13q34-qter.

By investigation of a German family pedigree with non-syndromic hearing impairment of early onset and autosomal-dominant mode of inheritance, linkage to known DFNA loci was excluded, and the existence of a new locus (DFNA33) was revealed. In a subsequent genomic scan the phenotype was mapped to a 6 cM interval on chromosome 13q34-qter. A maximum two-point lod score of 2.96 was obtained for the marker D13S285 with a maximum lod score in the multipoint analysis of 3.28 at 124.56 cM.

[A new locus for an autosomal dominant, non-syndromic hearing impairment (DFNA57) located on chromosome 19p13.2 and overlapping with DFNB15]. / Ein neuer Genort für eine autosomal dominante, nichtsyndromale Hörstörung (DFNA57) kartiert auf Chromosom 19p13.2 und überlappt mit DFNB15.

BACKGROUND: Non-syndromic hearing loss is the most genetically heterogeneous trait known in humans. To date, 54 loci for autosomal dominant non-syndromic sensorineural hearing loss (NSSHL) have been identified by linkage analysis. METHODS: In this study a German pedigree has been identified segregating a progressive bilateral loss of lower and middle frequencies. RESULTS: A genome-wide screening and linkage analysis revealed the existence of a new NSSHL locus (DFNA57). The phenotype was mapped to a 10 degrees Mbp interval on chromosome 19p13.2 from 7.8 to 18.2 degrees Mbp, a maximum 2-point LOD score of 3.08 was obtained for the marker D19S586. The region overlaps with the recessive locus DFNB15. CONCLUSION: The results underline the heterogeneity of hereditary hearing disorders. Identification of genes can help to reach a better understanding of the molecular mechanism of hearing.

[The use of melatonin as an alternative to sedation in children undergoing brainstem audiometry]. / Melatonin als Alternative zur Sedierung bei Durchführung einer Hirnstammaudiometrie bei Kindern.

BACKGROUND: Though one of the most important investigations in paediatric audiology, brainstem evoked response audiometry (BERA) often necessitates sedation or general anaesthetics, especially in newborn and infants. In paediatric neurology, melatonin has been successfully used for some years to induce sleep prior to EEG investigations. Melatonin as a hormone regulating the circadian rhythm induces natural sleep without the risks of sedation. Side effects are not known. METHODS: Click-induced BERA was first performed in 10 adults with normal hearing with and without previous melatonin administration, and click thresholds and latencies of evoked potentials were compared. 50 children then underwent BERA in melatonin-induced sleep. RESULTS: Click thresholds in adults were mostly identical (r = 0,88), while the mean latencies of evoked potentials seemed to be minimally prolonged (r from 0,82 to 0,95). Click-induced BERA was successful in 45 of the 50 children, and notched-noise BERA in at least 2 frequencies in 38 of 43 children. CONCLUSIONS: Offering a high success rate with no side effects, melatonin-induced sleep seems to be a good alternative to sedation. This method is widely accepted by parents and permits earlier diagnosis of hearing impairment in the routine clinical setting.

Utility of 24-h ambulatory blood pressure measurement in a routine clinical setting of patients with chronic renal disease.

The objective of the study was to investigate the utility of 24 h ambulatory blood pressure measurement (ABPM) in patients with chronic renal disease (CRD). A retrospective audit was performed in an academic nephrology department. ABPMs obtained from 95 consecutive outpatients with nondiabetic renal disease were analysed for their power to stratify disease severity and to predict progression of renal insufficiency during 3 years follow-up. The average of 10 consecutive office blood pressure (BP) readings performed at baseline was used as a reference. Correlations and tabulated statistics were calculated. Baseline mean diurnal BP was 138/87 mmHg by ABPM and 146/92 mmHg by average office BP (56.8 vs 25.3% normotensives, P < 0.01). Mean serum creatinine was 154 +/- 109 micromol/l. Patients without a circadian BP pattern (61%) had significantly higher serum creatinine, urinary albumin excretion and subsequent progression rates of renal failure (P < 0.05). Systolic and pulse pressure ABP values correlated significantly with serum creatinine levels at baseline and 3 years thereafter, independent of daytime (r = 0.23-0.60; P < 0.05). Abnormal nocturnal systolic and mean ABP, and pulse pressure but not average day office BP were significantly associated with abnormal serum creatinine and the presence of coronary heart disease at baseline (relative risk 1.6-1.7, P < 0.05). In conclusion, physicians considered ABPM preferentially in patients with borderline-controlled BP. ABPM provided significant additional information relevant to the clinical decision making process compared with average office BP alone thereby justifying its use in specific situations.

Differential distribution and expression of leptin and the functional leptin receptor in major salivary glands of humans.

Leptin plays a central role in the regulation of food intake and energy expenditure in rodents. However, it has become clear that this hormone has more than only a satiety-inducing function, and that there are other sources of leptin, such as the central nervous system, placenta and the gastrointestinal tract in addition to adipose tIssue. Knowing about the important role of the salivary glands in food intake and digestion, it was the objective of the present study to investigate how leptin and its receptor are expressed and distributed in the major salivary glands of humans. We found leptin distributed throughout the major salivary glands with obvious intracellular concentrations in granula. In contrast, immunostaining for the leptin receptor was found exclusively in the membranes of the glandular cells. A high density of the leptin receptor was localised in the epithelia of the duct lumen. PCR analysis proved the autonomous expression of leptin by the salivary glands independently from adipocytes. Accordingly the long receptor isoform was expressed by any examined tIssue. In the light of recent findings of leptin influencing the growth of rodent salivary glands, the presence and distribution of leptin and its receptor suggests an autocrine role of salivary leptin within the glands.

[Growth of sporadic vestibular schwannomas correlates with Ki-67 proliferation index]. / Das Wachstum von Schwannomen des Nervus vestibularis korreliert mit der Zellproliferation.

BACKGROUND: Sporadic vestibular schwannoma show a wide variability of their growth rate. Some tumors might remain quiescent for a long time without symptoms and other tumors might suddenly enlarge. Sometimes during surgical removal of tumors, it is useful to have a parameter for the prediction of the further growth potential of the schwannoma, especially if tumor resection results in functional impairment of the facial nerve. An often used histological parameter for growth rate of tumor cells is the proliferation index. METHODS AND PATIENTS: In our study we observed a series of 50 patients with neurinoma of the vestibular nerve by "wait and scan". After the first magnetic resonance imaging (MRI) all patients were controlled by a second MRI. The time between the MRIs ranged between 3 and 26 months (median 9). In 45 of 50 patients a surgical removal of the tumor by transtemporal approach followed. RESULTS: The proliferation index (Ki-67) was identified in the histological tumor specimens. The next step was the correlation of proliferation index and "tumor doubling time" (TDT). The volume of the tumors was provided by measuring three diameters of the tumors in MRI and calculating the volume with a formula. The volume of the tumors were used to calculate tumor growth and TDT. 10 patients showed no tumor growth during follow up. The average TDT in 40 cases was 22 months (SD 16). In 33 cases we were able to determine a proliferation index, which showed an average score of 1.99 %. Statistical analysis showed a correlation between proliferation index and TDT with a coefficient of - 0.42 (s: 0.014). In two cases with relevant clinical tumor growth (TDT: 12 months), the MIB-1 index was nearly 0 % in different areas of the tumor specimen. May be in these cases, the cell proliferation declined just before operation. On the other hand we found one patient with a high proliferation index of 3.3 % and a rather long TDT of 19 months. CONCLUSIONS: The determination of proliferation can serve as a further decision guidance during surgery of vestibular schwannoma.

[Surgical therapy of Madelung's disease in the head and neck area]. / Chirurgische Therapie des Morbus Madelung im Kopf- und Halsbereich.

PATIENTS AND METHODS: Between 1995 and 2001 we treated 12 patients with benign symmetric lipomatosis in the head and neck. The group comprised 11 men and 1 woman aged 34-62 (M=47). The most frequent complaints were diminished range of motion of the head and obstruction when eating or speaking. Combined lipectomy and liposuction were performed in all patients, with liposuction being carried out in a second session. RESULTS: The mean follow-up period was 3 years. The functional results were very satisfactory in all patients. Of the 12 patients, 9 were also satisfied with the aesthetic outcome.A recurrence occurred in three patients 1.5, 2, or 3 years after the operation. Severe complications were not observed. CONCLUSIONS: According to our experience, combined lipectomy and liposuction represents a successful procedure in treating benign symmetric lipomatosis in the head and neck region.Nevertheless, advantages and drawbacks of the two techniques should be equally considered prior to surgery.

Pericardial effusion in the nephrotic syndrome.

Hydropericardium is a known cause of pericardial effusion related to severely expanded extracellular fluid volume. Nephrotic patients have expanded extracellular fluid volume but obviously may have other causes for pericardial effusion. We tested the hypothesis that pericardial effusion is related to inflammation and not to hydropericardium in patients with nephrotic syndrome. Twenty nephrotic patients with systemic lupus erythematosus (SLE) were compared to 20 patients with nephrotic syndrome of other causes. No patient in either group had symptoms or signs of pericardial disease. Pleural effusion and ascites were equally common in SLE-nephrotic patients compared to non-SLE-nephrotic patients. However, 8 SLE patients had pericardial effusion, while none of the non-SLE-nephrotic patients had pericardial effusion. We suggest that hydropericardium is rare in nephrotic patients and that an inflammatory or other secondary cause should be considered when pericardial effusion complicates nephrotic syndrome.