Early nasal reconstruction after skin-preserving excision of squamous cell carcinoma of the nasal vestibule.

Surgery for early-stage squamous cell carcinoma of the nasal vestibule (SCCNV) may lead to facial disfigurement. We wanted to investigate if skin-preserving excision of SCCNV with reconstruction is oncologically, aesthetically, and functionally justifiable in cases with proximity to the skin. From 2010 to 2016, 16 patients underwent skin-preserving excision of T1-2 N0 SCCNV by a lateral rhinotomy approach at a tertiary referral center. The inner nose was reconstructed using a mucoperichondrial septal flap for the inner lining and a septal pivot flap and/or auricular cartilage grafting for the framework. Nasal appearance was measured on pre- and postoperative photographs. Median follow-up was 5.4 years. Three (19%) patients received adjuvant radiotherapy. Two (12.5%) recurrences occurred locally, but not at the site of preserved skin. The Kaplan-Meier estimate of local control rate after 5 years was 83%. All patients could be salvaged, giving an ultimate control rate of 100%. Nasal tip projection decreased by 6.7% (p < 0.001), and it was retained normal or near normal in 87.5% of patients. Nasal axis changed by 1.7° (p = 0.5). Nasal deviation occurred in 6.25% (1/16) of patients, and minor alar retraction in 6.25% of patients (1/16). Nasal breathing was normal or close to normal in 75% (12/16) of patients. Skin-preserving excision of SCCNV is oncologically justifiable in selected cases even in proximity to nasal skin. Early inner nasal reconstruction preserves nasal form and function to a high degree. This technique is a suitable alternative to rhinectomy and to avoid the sequelae of radiotherapy in selected cases.

Topographic bone thickness maps to evaluate the intuitive placement of titanium miniplates for nasal prostheses.

The aim of this study was to evaluate the intuitive placement of titanium miniplates. The hypothesis was that virtual planning can improve miniplate placement. Twenty patients were included in the study. These patients were fitted with 21 titanium miniplates (16 y-plates, three t-plates, and two u-plates) to retain nasal prostheses between 2005 and 2017. Colour-coded topographic bone thickness maps (TBTMs) were created in fused pre- and postoperative computed tomography. Implants were virtually transposed at the position of highest bone thickness. The bone thickness index (BTI) was calculated as the sum of points assigned at each screw (1 point per millimetre up to 4 mm, and 5 points for greater values) divided by the number of screws. One plate broke after 2.8 years, thus plate survival after 5 years was 91% using the Kaplan-Meier method. The BTI for all 21 plates increased from 3.4 to 4.1 points using virtual transposition (P<0.001). No significant changes were observed in t- and u-plates, but the median BTI increased from 3.1 to 4.1 points (P<0.0005) in 16 y-plates. The change was substantial (≥0.5 points) in 9/16 y-plates. Therefore, the hypothesis that virtual planning improves implant placement was accepted.

Measurement of bone thickness at the site of titanium miniplates used to retain nasal prostheses in fused computed tomographic data.

Our aim was to investigate the bone thickness at the site of titanium miniplates inserted to retain nasal prostheses. We studied 13 patients who had had titanium miniplates inserted for retention of nasal prostheses with a total of 60 titanium bone screws. A trajectory along each bone screw was segmented in fused computed tomographic (CT) data. Bone thickness was measured along this trajectory on the preoperative CT. The median bone thickness at the positions of the screws implanted on the frontal process of the maxillary bone was 1.4 (range 0.2-6.9) mm (mean 1.8). The median (range) values for men and women were 1.4 (0.2-6.9) mm and 1.3 (0.2-3.3) mm, respectively. The thickest bone was at the cranial part of the frontal process of the maxilla with a median of 2.0 (range 0.3-4.1) mm. However, differences in sex and position were not significant. None of the implant miniplates lost osseointegration. Despite the low bone stock at the lateral aspect of the pyriform aperture, survival of implanted titanium miniplates was 100% in this study group.

Primary surgical treatment of nasal vestibule cancer - therapeutic outcome and reconstructive strategies.

OBJECTIVE: The treatment strategy of squamous cell carcinoma of the nasal vestibule (SCCNV) is controversial. The objective of this study is to investigate the role of surgery, which is the preferred treatment option at our institution. DESIGN: This was a monocentric prospective study of patients that were diagnosed with SCCNV between 2005 and 2013. MATERIAL AND METHODS: Twenty-six patients were included. Tumors were staged using the UICC (7th edition) TNM classification of nasal cavity cancer and the classification proposed by Wang. The primary treatment was surgery in all patients. Survival data were statistically analyzed using the Kaplan-Meier method. The median follow-up time was 6 years. RESULTS: Using the UICC classification, 9/26 tumors were staged as pT1 (35%), 7/26 as pT2 (27%), and 10/26 as pT4a (39%). Using the classification by Wang, 9/26 tumors were staged as pT1 (35%), 15/26 as pT2 (58%), and 2/26 as pT3 (8%). Reconstruction was performed using an implant-retained prosthesis in 50% of patients and by plastic surgery in the remaining 50%. Only 2/26 patients (8%) needed adjuvant radiation therapy. The five-year recurrence-free survival (RFS) was 86.7%, disease-specific survival was 96.2% and overall survival was 91.8% after five years. CONCLUSION: Surgery in SCCNV gives an excellent prognosis and minimized the need for radiotherapy.

Quality of life after nasal cancer resection - surgical versus prosthetic rehabilitation.

BACKGROUND: Nose reconstruction following resection of nasal carcinomas is controversial. The objective of this study is to investigate the effect of surgical reconstruction versus prosthetic rehabilitation on patient quality of life (QOL). DESIGN: This was a monocentric prospective study of patients diagnosed with nasal carcinoma from 2003 to 2013. QOL was evaluated using two organ-specific questionnaires (Rhinoplasty Outcome Evaluation [ROE] and the Functional Rhinoplasty Outcome Inventory-17 [FROI-17]) and a generic questionnaire, the Short-Form 36 Health Survey (SF-36). MATERIAL AND METHODS: Sixty-four patients were included. Patients completed the ROE, FROI-17, and SF-36 questionnaires after nasal reconstruction. Questionnaires were completed by 62.8% of the 51 alive patients. RESULTS: Recurrence-free survival (RFS) was 89.9%, disease-specific survival was 94.5%, and overall survival was 75.5% after five years according to the Kaplan-Meier method. Considering initial tumor stage, early stage patients had a significantly higher self-confidence score in FROI-17 subgroup analysis. In contrast, advanced stage patients showed a significantly higher score for social functioning in SF-36. Prosthetically fitted patients scored highly on the ROE questionnaire showing a high degree of aesthetic satisfaction. Surgically reconstructed patients showed a high degree of self-confidence on the FROI-17 questionnaire. However, the organ-specific ROE and FROI-17 scores were not significantly different between patients who received surgical reconstruction and prosthetic rehabilitation after oncological resection. When comparing the rehabilitation method as a function of tumor stage, there was significantly better score for physical functioning in early stage surgically reconstructed patients in the SF-36, but no significant differences in organ-specific QOL. CONCLUSION: Surgical reconstruction and prosthetic rehabilitation after nasal cancer resection have the same effect on organ- and non-organ-specific QOL.

Mutant KIT as imatinib-sensitive target in metastatic sinonasal carcinoma.

Background: Sinonasal carcinomas (SNCs) comprise various rare tumor types that are characterized by marked histologic diversity and largely unknown molecular profiles, yet share an overall poor prognosis owing to an aggressive clinical course and frequent late-stage diagnosis. The lack of effective systemic therapies for locally advanced or metastatic SNC poses a major challenge to therapeutic decision making for individual patients. We here aimed to identify actionable genetic alterations in a patient with metastatic SNC whose tumor, despite all diagnostic efforts, could not be assigned to any known SNC category and was refractory to multimodal therapy. Patients and methods: We used whole-exome and transcriptome sequencing to identify a KIT exon 11 mutation (c.1733_1735del, p.D579del) as potentially druggable target in this patient and carried out cancer hotspot panel sequencing to detect secondary resistance-conferring mutations in KIT. Furthermore, as a step towards clinical exploitation of the recently described signatures of mutational processes in cancer genomes, we established and applied a novel bioinformatics algorithm that enables supervised analysis of the mutational catalogs of individual tumors. Results: Molecularly guided treatment with imatinib in analogy to the management of gastrointestinal stromal tumor (GIST) resulted in a dramatic and durable response with remission of nearly all tumor manifestations, indicating a dominant driver function of mutant KIT in this tumor. KIT dependency was further validated by a secondary KIT exon 17 mutation (c.2459_2462delATTCinsG, p.D820_S821delinsG) that was detected upon tumor progression after 10 months of imatinib treatment and provided a rationale for salvage therapy with regorafenib, which has activity against KIT exon 11/17 mutant GIST. Conclusions: These observations highlight the potential of unbiased genomic profiling for uncovering the vulnerabilities of individual malignancies, particularly in rare and unclassifiable tumors, and underscore that KIT exon 11 mutations represent tractable therapeutic targets across different histologies.

[Prosthetic treatment of nasal septal perforations : Results with custom-made silicone buttons]. / Epithetische Versorgung von Nasenseptumperforationen : Ergebnisse mit individuell angepassten Obturatoren aus Silikon.

BACKGROUND: Perforations of the nasal septum can be very disturbing for patients due to increased crust formation, nose bleeds, obstruction of nasal breathing and whistling sounds during nasal breathing. The aim of this study was to evaluate how the symptom burden can be alleviated by custom-made silicone buttons derived from an impression mold. MATERIAL AND METHODS: A retrospective study was carried out to evaluate 45 patients with symptomatic septal perforations, who have been treated over a period of 8 years. The magnitude and localization of the perforations were measured on the impression molds as well as in situ in 28 patients. The symptoms were rated on a visual analogue scale (VAS) before and after treatment (response 64%). RESULTS: No correlation was found between the size of the perforation and the distance from the nasal opening. Of the patients 31 (69%) still had the septal button in situ at the time of the last follow-up. The magnitude and localization of the perforation were not found to be predictors of treatment success. The following symptoms showed a highly significant improvement: crust formation (VAS median 75 vs. 31), nose bleeds (VAS median 50 vs. 0), obstruction of nasal breathing (VAS median 84 vs. 14) and whistling breathing sounds (VAS median 69 vs. 0). Unpleasant odor and symptoms of sinusitis did not show significant changes. The long-term septal button carriers rated the improvement with a median of 91% on the VAS. CONCLUSION: The success of prosthetic closing of septal perforations by a custom-made button still cannot be accurately predicted. The majority of patients were extraordinarily satisfied because the symptom burden could be significantly reduced.

Carbon ion therapy (C12) for high-grade malignant salivary gland tumors (MSGTs) of the head and neck: do non-ACCs profit from dose escalation?

PURPOSE: To evaluate the use of high-dose radiotherapy using carbon ions (C12) on non-adenoid cystic malignant salivary gland tumors (MSGT). PATIENTS AND METHODS: Between 2009 and 2013, patients with biopsy-proven non-ACC MSGT histologies of the head and neck received a combined regimen of IMRT plus C12 boost. Treatment toxicity (CTC v3), response (RECIST 1.1), control and survival rates were retrospectively analyzed. RESULTS: 40 patients with pathologically confirmed non-ACC MSGT (T4: 45 %; N+: 40 %; gross residual: 58 %; mucoepidermoid carcinoma (MEC): 45 %; adenocarcinoma: 20 %) were treated with a median of 74 GyE (80 Gy BED). Chemoradiation was given in 5 patients with MEC. Grade III acute toxicity was observed in up to 15 % (mucositis, dermatitis, dysphagia), no higher-grade late toxicity occurred to date. At a follow-up of 25.5 months, LC, and PFS at 2 and 3 years are 81.5 % (LC) and 66.8 % (PFS), OS at 2 and 3 years is 83.6 % and 72.8 %. Most frequent site of disease progression was distant metastasis. Histologic subtype correlated with LC and PFS. Resection status (gross vs microscopic disease) had no significant effect on LC, PFS, or OS. CONCLUSION: The treatment is well tolerated, no higher grade late effects were observed. Considering the negative pre-selection, LC, PFS and OS are promising. While histology and site of origin significantly influenced control and survival rates, resection status did not, potentially due to the effect of dose escalation.

[Percutaneous titanium implants for bone conduction hearing aids: experience with 283 cases]. / Perkutane Titanimplantate für Knochenleitungshörgeräte: Erfahrungen mit 283 Fällen.

BACKGROUND: By virtue of direct bone conduction, percutaneous bone-anchored hearing implants offer a high level of wearing comfort, as well as audiologically superior signal transmission due to less dampening. Over the years, titanium implants have been optimized and the surgical technique developed into a minimally invasive intervention without soft tissue reduction. This study aims to investigate the success rates of the various percutaneous implant systems. MATERIALS AND METHODS: This retrospective study includes 191 patients who received a total of 283 percutaneous titanium implants for bone conduction hearing systems during the period from 01.01.1989 until 31.12.2013. Patient age ranged from 2 to 81 years (mean 36 years). The mean follow-up duration was 5.2 years. RESULTS: The overall osseointegration success rate was 92.6% and ranged from 90.5 to 100% for the various implant systems (p = 0.6). For children and adolescents, the success rate was 86.8%, compared to 95.2% in adults (p = 0.023). Classical soft tissue reduction was received by 185 patients, mainly via the dermatome technique. The linear incision technique was used in 3.8% of cases and the technique without soft tissue reduction in 3.7% of cases. Revision surgery for soft tissue problems was performed in 4.2% of cases. CONCLUSION: Success rates in adults were significantly higher than those in children and adolescents. Although success rates improved with the development of new systems, this did not reach statistical significance. Minimally invasive surgery without soft tissue reduction is considered state of the art.

[A new implant system for orbital prosthetic rehabilitation: "epiplating mono"]. / Ein neues Implantatsystem für die epithetische Orbitarehabilitation: "Epiplating Mono"

A New Implant System for Orbital Prosthetic Rehabilitation: "Epiplating Mono" Prosthetic or episthetic rehabilitation of ear, eye and nose are currently most common performed using magnetic fixation. While at the beginning single implants have been used, now-a-days a more extended approach with plate fixation are recommended to enhance the stability of the anchored magnets. A newly designed implant system epiplating mono is presented that combines the structure of a single implant with additional fixation elements. In a pilot study this new implant system was used in 4 patients for prosthetic orbital rehabilitation. Further experiences with this new implant system are required necessitating long-term experiences of implant stability to define the value of the presented epiplating mono system for prosthetic rehabilitation.

[Reconstruction of maxillary defects using a free scapular angle flap]. / Rekonstruktion von Oberkieferdefekten mit einem freien Skapula-angle-Lappen.

BACKGROUND: In addition to prosthetic rehabilitation, maxillary defects can also be surgically reconstructed. Soft-tissue reconstruction employs a radial forearm or latissimus dorsi muscle flap, while bony reconstruction can be achieved using a fibula, iliac crest, or scapular flap. Reconstruction using a scapular flap is further divided into two subgroups: the traditional scapular flap with the circumflex scapular artery as the donor vessel and the scapular angle flap with the angular artery originating from the thoracodorsal artery as the donor vessel. MATERIALS AND METHODS: We report on four patients who underwent successful reconstruction with a free scapular angle flap between 2009 and 2011, following maxillary resection due to malignancy. RESULTS: Vertical positioning of the scapular angle flap enables reconstruction of the facial contour, whereas its horizontal alignment and microvascular anastomosis makes a bony reconstruction of the hard palate possible. CONCLUSIONS: The versatility, low rate of donor site morbidity and shape of the scapular angle flap--which resembles that of the hard palate--render it ideal for plastic reconstruction. The suitability of bone quality for dental rehabilitation with implants is a topic of controversial discussion. The scapular angle flap represents an alternative to obturator prosthesis for the reconstruction of maxillary defects ≥ grade I according to Okay et al.

[Craniofacial prostheses for facial defects]. / Epithetische Versorgung von Gesichtsdefekten.

Craniofacial prostheses (or epitheses) are artificial substitutes for facial defects. Today, prostheses made of silicone are state-of-the-art. They may be fixed anatomically (to already existing structures), mechanically (to spectacle frames), chemically (using adhesives), or surgically (to osseointegrated titanium implants). With the existing extraoral implant systems, prostheses may be securely anchored to the bone regardless of size and location of the defect. The classic atraumatic surgical technique has remained an unchanged prerequisite for successful implantation by avoidance of any heat trauma to the bone. This review outlines the indications and contra-indications as well as advantages and disadvantages of craniofacial prostheses and their retention methods in various facial regions. It summarizes the basic principles of extraoral implantology in respect to implant positioning and the management of children and radiated patients.

[New developments in computer-assisted surgery (CAS). From intraoperative imaging to ultrasound-based navigation]. / Neue Entwicklungen in der computerassistierten Chirurgie. Von der intraoperativen Bildgebung bis zur ultraschallbasierten Navigation.

Ever faster processor capacity is having an impact on computer-assisted or computer-aided surgery (CAS). The fusion of different imaging modalities enables functional data such as PET-CT, for example, to be available in image-guided surgery. Referencing of image data is the key to precise navigation. Intraoperative data acquisition is a new approach to improving accuracy. Thus, intraoperative CT conducted under navigational support enables automatic referencing of up-to-date image data. Alternatively, intraoperative magnetic resonance imaging or intraoperative sonography can be performed. Ultrasound systems have already been successfully integrated in existing navigational systems to compensate for intraoperative tissue shifting. Ultrasound systems may play a role in the future as a single modality in image-guided surgery in soft tissue of the neck and skull bone.

[Bone anchored hearing aids (BAHA)]. / Knochenverankerte Hörgeräte (BAHA).

Bone anchored hearing aids (BAHA) achieve optimal acoustic coupling by means of direct bone conduction via an osseointegrated percutaneous titanium implant. Currently this system has a record of over 30 years of clinical application and reliability. Patients with bilateral hearing loss with air-bone gaps will benefit from bilateral BAHA fitting. Likewise, unilateral conductive hearing loss with normal hearing on the other side can be treated with a BAHA. New developments in this field include the BAHA Intenso and also novel implant systems, such as the Epiplating system by Medicon, the alpha system by Otomag and the OBC system by Otorix. Due to the advantages of the BAHA system (possibility of preoperative testing, simple surgery without the risk of inner ear damage, MRI compatibility, etc.), the BAHA will keep its important role in hearing rehabilitation even in the era of other partially and totally implantable hearing devices.

[Implant retained epistheses for facial defects]. / Implantatgetragene Epithesen zur Versorgung von Gesichtsdefekten.

Epitheses, also known as craniofacial prostheses, are artificial substitutes for facial defects. The breakthrough for rehabilitation of facial defects with implant retained epitheses came with the development of the modern silicones and bone anchorage. After the discovery of the osseointegration of titanium in the 1960s, dental implants have been made of titanium. In 1977, the first extraoral titanium implant was inserted in a patient. Later, various solitary extraoral implant systems have been developed. Besides, grouped implant systems have been developed, which may be placed more reliably in areas with low bone offering, as in the nasal and orbital region, or the ideally pneumatised mastoid process. Today, even large facial epitheses may be securely retained. The classical atraumatic surgical technique has remained an unchanged prerequisite for successful implantation of any system. This review outlines the basic principles of osseointegration as well as the main features of extraoral implantology.

[Methicillin-resistant Staphylococcus (MRSA, MRSE) in the nose, paranasal sinuses and sputum]. / Methicillinresistente Staphylokokken (MRSA, MRSE) im Nasen-, Nasennebenhöhlenbereich und Sputum.

Detection of Staphylococcus in humans can be of extremely varying importance ranging from commensal to pathogens of fatal infections. MRSAs in particular are iatrogenic and nosocomial infective pathogens, which are a threat to the success of medical treatment. In this review the causes for occurrence and the spread of MRSA are presented and the heterogeneity of MRSA due to the presence of additional resistant pathogens (VISA, VRSA) and pathogenetic forms (cMRSA) will be discussed. The current diagnostic and therapeutic procedures in various situations for MRSA in the nasal and paranasal sinuses and sputum will be discussed exemplified by an actual case. The danger of colonization by MRSA will be discussed with reference to the literature as nasal colonization can be accompanied by a greatly increased risk of an invasive infection and transmission of the pathogen to other persons.

[Update on computer- and mechatronic-assisted head and neck surgery in Germany]. / Update in der navigiert kontrollierten und mechatronisch assistierten Kopf-Hals-Chirurgie in Deutschland.

A consequence of the ongoing advances in medical navigation is the development of so-called mechatronic assistant systems. Up to now, medical navigation had been used only for additional intrasurgical orientation. But improvements in accuracy in imaging and medical navigation can exceed the surgeon's possible manual accuracy of surgical manipulation. In such cases, mechatronic assistant systems can supplement certain surgical procedures in order to obtain the required precision, such as for positioning of implants. The development and possible use of such mechatronic assistant systems in the head and neck, as well as improvements in the accuracy of medical navigation, are the focus of several working groups. For coordinating and adapting the various research projects, different research groups were called to present their current projects and results in the context of ASKRA (working group for skull-base and craniofacial surgery of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery) workshops at the German Society for Computer- and Robot-Assisted Surgery (CURAC) convention on 14 October 2006 in Hanover. Different projects were presented, with topics including navigated controlled assistant systems for the frontal and lateral skull base, possibilities for sonographic-induced bone measurement, and requirements for high-precision surgery of the skull base.