[Terbinafine-resistant dermatophytoses and onychomycosis due to Trichophyton rubrum]. / Terbinafin-resistente Dermatophytosen und Onychomykose durch Trichophyton rubrum.

BACKGROUND: In recent years, therapy-refractory courses of dermatophytoses have increasingly become the focus of attention. The most frequent pathogens are Trichophyton (T.) rubrum and T. mentagrophytes. In addition to local therapy, first-line treatment includes terbinafine, an allylamine antifungal agent that acts by inhibiting squalene epoxidase and thus interfering with ergosterol synthesis. In refractory cases, terbinafine resistance due to point mutation in the squalene epoxidase gene has been frequently detected. OBJECTIVES: The aim is to present specific aspects in the epidemiology of dermatophytoses with terbinafine resistance and to illustrate them on the basis of four patient cases including diagnostic procedures. MATERIALS AND METHODS: A review of handbook knowledge, a selective literature search, and a review of four patient cases were performed. RESULTS: Detection of the terbinafine resistance was performed by in vitro testing using the breakpoint method as well as sequencing of the Trichophyton isolate and detection of the point mutation with amino acid substitution at position L393F or F397L of squalene epoxidase. CONCLUSION: In refractory and recurrent dermatophytoses, terbinafine resistance should be considered, especially in T. mentagrophytes and T. rubrum, and in vitro resistance testing of the dermatophyte and point mutation analysis of squalene epoxidase (SQLE) should be performed. Therapeutically, intermittent administration of itraconazole in combination with antifungal local therapy is recommended. Nevertheless, a recurrent course is to be expected and long-term therapy with itraconazole is usually necessary.

[Imaging of the paranasal sinuses and anterior skull base]. / Bildgebung der Nasennebenhöhlen und der Frontobasis.

Due to the complex anatomy of the anterior skull base and paranasal sinuses, radiologic diagnostics in this area are challenging. Magnetic resonance imaging (MRI) and computed tomography (CT) are the primary indicated modalities. Guidelines helping to select the appropriate modality have been published by the German Society of Head and Neck Radiology and the Society of Otorhinolaryngology. The present article presents an overview of the current radiologic procedures and their optimized implementation using clinical examples. These examples highlight the fact that a combination of at least CT and MRI is frequently required. Use of CT for intraoperative navigation is everyday practice in clinical routine. Occasionally, additional procedures such as angiography or myelography are necessary, particularly in cases of preoperative vascular diagnostics or embolization. Overall, evaluation of radiologic diagnostics in this area is complex; it requires experience and knowledge of the disease, as well as an understanding of the diagnostic procedures. Close collaboration between head and neck surgeons and radiologists is thus essential.

[Clinical otorhinolaryngological symptoms of metamizole-induced agranulocytosis]. / Klinische Symptome der metamizolinduzierten Agranulozytose in der HNO.

BACKGROUND: Despite the controversial international debate on the use of metamizole as a standard analgesic, the prescription figures for Germany have increased constantly during recent years. However, metamizole can lead to the rare and severe medical condition called agranulocytosis. MATERIALS AND METHODS: Between January 2009 and January 2014, 5 patients with metamizole-induced agranulocytosis presented themselves at the Interdisciplinary Emergency Center of the University Clinic Bonn. According to their leading ENT symptoms, they were transferred to the otorhinolaryngological department. We retrospectively evaluated metamizole medication, all general patient data and previous diseases, as well as disease course and the respective therapies. RESULTS: Within the scope of the different treatments--surgery after trauma (n=2), elective orthopedic surgery (n=2), tonsillitis treatment (n=1)--the patients (n=5; mean age 30 years) had made regular ambulant use of metamizole for several days or weeks (4-28 days, mean 16.8 days). Daily oral dose ranged from 625 to 2000 mg/d (mean 1500 mg/d). Subsequently, patients required treatment for clinical symptoms of agranulocytosis (e.g. tonsillitis with severe odynophagia and significantly reduced general condition). All patients were monitored in an intermediate or intensive care unit (3-14 days, mean 10 days). No patients died. DISCUSSION: As our cases show, when using metamizole as a standard analgesic, the treating otolaryngologist should look for clinical symptoms of agranulocytosis and inform patients about possible adverse effects. We recommend strict indication setting, regular blood analyses during long-term medication and consideration of alternative analgesics (e.g. NSAR).

Multiple causes for rhinolithiasis.

BACKGROUND: Rhinoliths are rare affections of the main nasal cavity and the paranasal sinuses. Initially, as a result of their low incidence, they are often incorrectly classified as calcified tumors in clinical examination. METHODOLOGY: We have identified three cases in our patient population and evaluated the clinical symptoms as well as the pathological findings and the causes of the disease. RESULTS: Due to their extension and the respective clinical pattern, all masses were surgically removed under endotracheal anesthesia. The histopathological findings comprised an ectopic tooth, a vegetable (most likely a leaf from the garden) as well as a textile foreign body (probably of iatrogenic origin). CONCLUSION: Undiscovered foreign bodies of the main nasal cavity are a common cause for the formation of rhinoliths. We have also displayed the respective incidence and the therapeutic options.

[Analysis of quality of life outcome for nasopharyngeal carcinoma patients after treatment]. / Posttherapeutische Lebensqualität beim Nasopharynxkarzinom.

BACKGROUND: This retrospective study analysed patient characteristics and quality of live (QoL) for patients with nasopharyngeal carcinoma (NPC) after treatment. MATERIAL AND METHODS: A cross-sectional investigation was conducted to assess the QoL of 20 NPC patients with cancer-free survival of more than one year, which were treated with radiotherapy (RT) or chemoradiotherapy (RCT) during the period 2001-2009 at the University Hospital Bonn, Germany. The QoL was assessed by the FACT-NP (functional assessment of cancer therapy-nasopharyngeal) questionnaire. RESULTS: The median age of the patients was 57 ± 13 years and the male/female ratio was 2.33/1.3 (15%) patients were treated with RT and 17 (85%) with RCT. The global QoL was good in our patients. Xerostomia, chewing, decrease of gustatory sense, discontent with sexual life and ear problems were of major concern with the majority of patients and affected the QoL negatively. Pain, lost of working ability, emotional distress, or family problems were no significant factors. CONCLUSION: The expected reduction of QoL after treatment must be explained in detail to the NPC patient. The integration of the family and partner, an antidepressant therapy or psycho-oncological support can be useful and necessary.

[Sinonasal tract malignancies : a 14-year single institution experience]. / Maligne Erkrankungen des Sinunasaltrakts : Eine monoinstitutionelle Erfahrung von 1996 bis 2010.

BACKGROUND: With a worldwide annual incident rate of 1/200,000 sinonasal tract malignancies are a relatively rare disease. MATERIAL AND METHODS: All patients with sinonasal malignancies (n = 177) treated between 1996 and 2010 at the Department of Head and Neck Surgery, University of Bonn, Germany were analyzed retrospectively. Data on age, gender and incidence were available for all patients but other demographic data, treatment regimes and outcome were only analyzed for carcinomas. RESULTS: Carcinomas were the most frequent histological diagnosis (58%). Unspecific sinonasal symptoms lasted on average for 4.7 ± 5 months before primary diagnosis. Interestingly, 64% of patients with sinonasal carcinoma presented with locally advanced disease (T3-4) but only 15% displayed corresponding regional lymph node metastases. The overall 3-year survival rate was 61%. Patients solely needing surgical treatment displayed a better survival rate than patients receiving combined surgery and adjuvant treatment or definitive radio(chemo)therapy. Multivariate analysis revealed a T-stage classification as the only independent prognostic factor for 3-year survival. CONCLUSIONS: Due to unspecific symptoms most sinonasal malignancies are diagnosed at an advanced stage of the disease and despite multimodal therapies these tumors still have an unfavorable prognosis.

[CT rhinometry : a correlation of rhinomanometry and multiplanar computer tomography of the nasal cavity]. / CT-Rhinometrie : Korrelation der Rhinomanometrie mit multiplanarer Computertomographie der Nasenhaupthöhle.

BACKGROUND: Otorhinolaryngologists require new diagnostic methods to give further insight into the physiology of nasal breathing. The functional aspects of radiological data in the field of ENT have rarely been examined. This study compares computed tomography (CT) scan area measurements of the paranasal sinuses with physiological data from rhinomanometry. PATIENTS AND METHODS: In a retrospective study, paranasal CT scans from 36 patients were analysed for volume, width and hydraulic diameter of the five key regions of the nasal cavity (CT rhinometry) and compared to the active anterior rhinomanometric (RMM) results representing the gold standard in nasal flow description. RESULTS: The highest correlation between the rhinomanometric results and CT rhinometry was found at the internal ostium, followed by the diffuser region. The structures important for regulating nasal flow could thus be identified in the CT area data. CONCLUSION: CT rhinometry revealed structures important for nasal breathing, in addition to providing anatomical and topographical data. CT rhinometry measured volumes, width and hydraulic diameters of the nasal cavity correlated with measurements of transnasal flow.

[Treatment results of nasopharyngeal carcinoma in adults]. / Ergebnisse beim Nasopharynxkarzinom im Erwachsenenalter.

BACKGROUND: Nasopharyngeal carcinoma (NPC) is a rare tumor entity in Germany in contrast to endemic countries in Asia or Africa. This retrospective study investigated patient characteristics and prognostic factors with respect to different NPC treatment strategies. PATIENTS AND METHODS: A total of 63 NPC patients treated during the period 1990-2009 at the University Hospital Bonn, Germany, were included. RESULTS: The median age of the patients was 56.4 years, the male:female ratio was 3.2:1, 23.8% were in Union Internationale Contre le Cancer (UICC) stage I/II and 76.2% were in stage III/IV. Most of the carcinomas were WHO type III (57.1%), followed by World Health Organization (WHO) type II (33.3%) and at last WHO type I (9.6%). The 5-year overall survival rate after concomitant chemoradiotherapy (RCT) was 75% and after radiotherapy (RT) 60%. The mortality rate increased by 3.5 times with each increase in T-stage (p ≤ 0.047). The recurrence rate (RR) after RCT was 34% and after RT alone 68% (p ≤ 0.04). Tumor ablation increased the RR significantly (p ≤ 0.047). CONCLUSION: Combined chemotherapy and RT is an effective treatment of NPC disease and clearly superior to RT alone. Tumor ablation before RCT/RT worsens the prognosis and is now obsolete.

[Initial diagnosis of head and neck tuberculosis]. / Erstdiagnose einer Tuberkulose im HNO-Bereich.

BACKGROUND: In Germany tuberculosis has a decreasing incidence. The lung is the most common focus, whereas head and neck manifestation occurs rarely. MATERIAL AND METHODS: Between 1997 and 2010 all patients with initial diagnosis of tuberculosis of the head and neck region were retrospectively reviewed at the University Hospital of Bonn, Germany. RESULTS: 38 patients (24 female, 14 male, median age 43.5±19.7 years) were analysed. More than 60% were of foreign nationality. The majority of patients (87% ) presented with an unspecific cervical lymph node swelling. Extranodular manifestations (maxillary sinus, middle ear, larynx, tonsil) leading to organ specific symptoms rarely occurred. In only 3 cases a mycobacterial infection was suspected before surgery. CONCLUSION: Only the knowledge of different manifestation patterns as well as an accurate anamnesis of infectious diseases can lead to the tentative diagnosis of tuberculosis prior to surgery.

Clinical requirements and possible applications of robot assisted endoscopy in skull base and sinus surgery.

Functional Endoscopic Surgery of Paranasal sinuses (FESS) and Skull Base surgery is one of the most frequent surgeries performed at the ENT department of the Bonn University, Germany. Beside of surgical Navigation Robotic is one of the upcoming fields of Computer assisted Surgery developments. This work presents novel research and concepts for Robot Assisted Endoscopic Sinus Surgery (RASS) of the Paranasal sinuses and the anterior Skull Base containing the analysis of surgical workflows, the segmentation and modelling of the Paranasal sinuses and the anterior Skull Base and the development of the robotic path planning. An interdisciplinary group of software engineers and surgeons in Braunschweig and Bonn, Germany are approximate to solutions by a clinical and technical research program financed through the DFG (Deutsche Forschungsgemeinschaft, German research Community).

Surgical excision of basal cell carcinoma with complete margin control: outcome at 5-year follow-up.

BACKGROUND: The incidence of skin cancer and especially basal cell carcinoma (BCC) has increased in the last few decades. The gold standard of care is usually a surgical excision, but it also has the risk of local recurrence depending on tumor characteristics. OBJECTIVES: We analyzed the 5-year cure rates after surgical excision of BCC with complete margin control using paraffin-embedded sections. METHODS: A retrospective analysis of 671 patients (45.3% male, 54.7% female) with 777 primary and 85 with recurrent BCC were collected during 2001-2003. All patients underwent surgery with complete margin control using paraffin-embedded sections. When the histological examination revealed a positive margin, another surgical step was performed in the area of residual tumor. RESULTS: Five-year follow-up examinations were possible in 630/862 (73.1%) of patients with BCC. In the group with primary BCC (n = 562), 3 tumor recurrences (0.5%) were identified; in the group with recurrent BCC (n = 68), 2 tumor recurrences (2.9%) were seen, resulting in an overall 5-year recurrence rate of 0.8% for all patients with BCC. The mean tumor recurrence time after surgery was 36.6 months. CONCLUSION: Local complete tumor resection confirmed by complete margin control using paraffin-embedded sections can achieve excellent cure rates for both primary and recurrent BCC.

On-line preferential solvation studies of polymers by coupled chromatographic-Fourier transform infrared spectroscopic flow-cell technique.

Qualitative and quantitative comparison between liquid chromatography (LC) and LC coupled with Fourier transform infrared spectroscopy (LC-FTIR) to evaluate preferential solvation phenomenon of polymers in a mixed solvent has been performed. These studies show that LC-FTIR technique leads to detailed structural information without the requirement for determination of additional parameters for quantitative analysis except calibration. Appropriate experimental conditions for preferential solvation study have been established by variation of polymer concentration, molar mass and eluent content.

Efficacy of a polyurethane dressing versus a soft silicone sheet on hypertrophic scars.

OBJECTIVE: To compare the efficacy and safety of a polyurethane dressing with a silicone sheet in the treatment of hypertrophic scars. METHOD: Sixty patients participated in this intra-individual 12-week clinical trial. Each scar was divided into two areas, to which the polyurethane dressing and the silicone sheet were randomly allocated. The primary outcome measure was the percentage change in the overall scar index (SI) between baseline and week 12. Secondary outcome measures included changes in skin redness, objectively measured by chromametry, and patients views on the aesthetic outcome of treatment. RESULTS: Both therapies achieved favourable results for all of the above outcome measures. Results were comparable for the primary outcome measure: 29.4% versus 33.7% for the silicone sheet and polyurethane product respectively. The decrease in the overall SI was significantly more pronounced for the polyurethane product after week 4 (5.6% versus 15.8% for the silicone sheet; p<0.0001) and week 8 (20.2% versus 27.1%; p=0.012). CONCLUSION: Both regimens were associated with a significant reduction in the clinical signs of hypertrophic scars over 12 weeks of treatment. The polyurethane dressing demonstrated a significantly more pronounced reduction in severity of these clinical signs after four and eight weeks of treatment and was better tolerated than the silicone sheet. l DECLARATION OF INTEREST: This study was funded by Beiersdorf AG. proDERM is an independent research company, and none of the authors have an interest in the sponsors commercial activities.

[Evaluation of force data with a force/torque sensor during FESS. A step towards robot-assisted surgery]. / Sensorbasierte Messung mechanischer Kräfte am Endoskop während FESS. Schritte zur robotergestützten Nasennebenhöhlenchirurgie.

BACKGROUND: To relieve the surgeon during functional endoscopic endonasal sinus surgery (FESS), the endoscope should be guided by autonomous robot assistance. The surgeon will thus have two hands free for suctioning and manipulation during FESS. PATIENTS/METHODS: With a force/torque sensor mounted on the endoscope, we measured forces in six degrees of freedom in five cadaver heads and in 20 actual endoscopic sinus procedures. On the cadaver heads we performed complete endoscopic endonasal dissection of all paranasal sinuses. All forces at the endoscope were monitored continuously. RESULTS: The mean forces occurring at the endoscope were 3.2 N. There were only slight differences between the in vivo and ex vivo data. We measured peak forces up to 25.2 N. In 95% of all cases, forces were lower than 7 N. CONCLUSION: Forces up to 7 N are sufficient for endoscopic guidance during FESS. Peak forces are distinctive for endoscopic guidance by humans and could be optimised by sensor-based intraoperative robot guidance. Higher forces are required for surgical endoscopy of the frontal and maxillary sinuses compared with the ethmoid sinuses.