[Assessment of primary and secondary misallocations in the German Diagnosis Related Groups (G-DRG) system in otorhinolaryngology]. / Begutachtung der primären und sekundären Fehlbelegung im German Diagnosis Related Groups (G-DRG) System in der HNO-Heilkunde.

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.

[Assessment of Coding in German Diagnosis Related Groups System in Otorhinolaryngology]. / Begutachtung der Kodierung im German Diagnosis Related Groups System in der HNO-Heilkunde.

BACKGROUND: Prospective analysis of assessment reports in otorhinolaryngology for the period 01-03-2011 to 31-03-2017 by the Health Advisory Boards in Lower Saxony and Bremen, Germany in relation to coding in the G-DRG-System. MATERIAL AND METHODS: The assessment reports were documented using a standardized database system developed on the basis of the electronic data exchange (DTA) by the Health Advisory Board in Lower Saxony. In addition, the documentation of the assessment reports according to the G-DRG system was used for assessment. Furthermore, the assessment of a case was evaluated once again on the basis of the present assessment documents and presented as an example in detail. RESULTS: During the period from 01-03-2011 to 31-03-2017, a total of 27,424 cases of inpatient assessments of DRGs according to the G-DRG system were collected in the field of otorhinolaryngology. In 7,259 cases, the DRG was changed, and in 20,175 cases, the suspicion of a DRG-relevant coding error was not justified in the review; thus, a DRG change rate of 26% of the assessments was identified over the time period investigated. CONCLUSIONS: There were different kinds of coding errors. In order to improve the coding quality in otorhinolaryngology, in addition to the special consideration of the presented "hit list" by the otorhinolaryngology departments, there should be more intensive cooperation between hospitals and the Health Advisory Boards of the federal states.

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.

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.

Peri- and postoperative complications after laser surgery of tumors of the upper aerodigestive tract.

BACKGROUND: Because of the increasing use of laser surgery for tumors of the upper aerodigestive tract, there is also a discussion in peri- and postoperative complications of this kind of surgery. It was the aim of the present investigation, based on a great number of treated patients, to point out the complications of laser surgery and give a hint for possible dangers. PATIENTS AND METHODS: Altogether, 1528 patients suffering from tumors of the upper aerodigestive tract were investigated. The peri- and postoperative complications were assumed in respect to localization and stage of tumor. RESULTS: The different evidence of complications depended on the localization and stage of tumor. It was pointed out that postoperative bleeding is the main complication after laser surgery of tumors of the upper aerodigestive tract. Overall, there were low complication rates especially after surgery of glottic carcinomas in early stages. CONCLUSIONS: Peri- and postoperative complications after laser surgery of tumors of the upper aerodigestive tract are relatively seldom events. Because of the fact that postoperative bleeding is the most common complication, every clinic that performs laser surgery should have a clear concept of management for this complication. Also, strategies to avoid these complications should be developed.

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.

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.

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.

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.