Nasal airway changes after Le Fort I--impaction and advancement: anatomical and functional findings.

Twenty patients were studied prospectively to assess intranasal anatomical changes and functional changes resulting from a one-piece Le Fort I-osteotomy with anterior and superior positioning of the maxilla. Presurgical and 3 months postsurgical rhinological inspection, anterior rhinomanometry and acoustic rhinometry were performed. Interalar width was measured and cephalograms were used to assess maxillary movement. Rhinoscopically, three septal perforations (15%) were noticed. Turbinate enlargement was less common postoperatively. Interalar width increased significantly. These findings correlate with a significant increase in cross-sectional diameter at the Isthmus nasi revealed by acoustic rhinometry 3 months postoperatively. The mean total nasal airflow measured by anterior rhinomanometry was unchanged indicating no increase in resistance despite decreased intranasal dimensions in cases where the impaction is not higher than 5 mm.

[Inverted papilloma of the nose and paranasal sinuses. Long-term outcome of endoscopic endonasal resection]. / Invertierte Papillome der Nase und ihrer Nebenhöhlen. Langzeitergebnisse nach endoskopischer endonasaler Resektion.

There is still some skepticism about endoscopic endonasal resection of inverted papillomas. We conducted a long-term retrospective study and examined 104 patients (82 male, 22 female) with inverted papilloma who were operated at the ENT-Department of the University of Erlangen between 1974 and 1997. The endoscopic approach was chosen in each case, either alone or in combination with external approaches. In 64.4% (67 cases), tumors of all T-classes were resected by endoscopic approach alone (T1:17.9%, T2:23.9%, T3:41.8%, T4:16.4%). For the rest of the patients an additional transoral and transfacial approach was necessary due to difficult tumor localization (T2:24.3%, T3:29.7%, T4:45.9%). The mean age of the patients was 55 years. The recurrence rate after primary endoscopic endonasal sinus surgery was 22.4% (15/67) and after combined endoscopic and external surgery 16.2% (6/37). Second salvage surgery after endoscopic sinus surgery was performed again endonasally in 46% (7/15) and externally in 53.3% (8/15). The recurrence rate after the endonasal approach was now 57.1% (4/7) and 50% (4/8) after external surgery. Third salvage surgery was performed again endoscopically in four cases and externally in four cases. The recurrence rate in both groups was 50% each, so that up to six operations, either endoscopically or externally, were necessary for complete tumor resection. The longest period for a tumor recurrence was 3.4 years after endoscopic sinus surgery and 9 years after combined endoscopic and external surgery. A tumor recurrence after endoscopic endonasal sinus surgery that could not be managed endoscopically again occurred in 12%. Tumor localization is the limiting factor for endoscopic endonasal sinus surgery of inverted papilloma. However, in 64.4% of cases, endoscopic endonasal sinus surgery alone was performed successfully without any loss of one patient. Long-term follow-up is necessary since the recurrence of tumor can happen after a long time. Endoscopic endonasal sinus surgery of inverted papilloma is safe and should be preferred due to its minimal invasive character.

[Ligature of the carotid arteries performed prophylactically or as an emergency procedure in patients with malignant tumours of the head and neck]. / Prophylaktische und notfallmässige Unterbindungen der Aa. carotides bei Patienten mit malignen Tumoren im Kopf-Hals-Gebiet.

Life threatening hemorrhage in patients with malignant tumours of the head and neck area are often, as a result of tumour infiltration, postoperative anatomical changes, infection and radiological necrosis, difficult to control. One option for prophylaxis and treatment is the ligature of the external (ECA) or common carotid artery (CCA) and superior thyroid artery (STA). 52 patients were examined in a retrospective study to determine both the hazards and the therapeutic use of the procedure. The external carotid artery (ECA) was ligated prophylactically during the operative procedure of tumour resection and neck dissection in 25 patients. In 27 cases closure of the ECA, CCA or ECA and STA was carried out as an emergency procedure for acute hemorrhage following completed primary treatment (operation, primary or postoperative radiation or radiochemotherapy). There was no postoperative hemorrhage after prophylactic ligature of the ECA. One patient with multiple cardiovascular diseases suffered from an ipsilateral cerebral infarction 1 year after operation. In 6 of 9 patients and in all 3 patients, in whom ligature of the CCA or ECA and STA respectively was carried out as an emergency procedure, severe neurological complications up to an apallic syndrome occurred. The number of deaths due to acute hemorrhage was considerably smaller among those patients with prophylactic ligature of the ECA performed during operative procedure of tumor resection and neck dissection. In addition there were much less unfavourable courses in the sequence of prophylactic closure of the ECA than observed after ligating the CCA or ECA and STA in an emergency situation.

[Prospective investigations on the spontaneous healing of intraoperative lesions of the mucosa of the nasal septum]. / Prospektive Untersuchungen zur Spontanheilung von Septumschleimhauteinrissen bei rhinochirurgischen Eingriffen. Vorläufige Mitteilung.

Mucosal lesions of the nasal septum during septal surgery are frequent, but there is scarce information in the literature about their outcome. In 283 operations of the nasal septum, 92 (32.5%) mucosal lesions occurred, 67 of these could be documented and classified 1, 3 and 6 months postoperatively. Although there was no therapy in 93% (74 cases) of the one-sided lesions, no permanent septal perforation was seen. A total of 7% (six cases) were treated by suture or lyophilised dura combined with tissue adhesive. On the other hand, double-sided and correspondent lesions (12 cases: six without therapy, four sutures, one lyophilised fascia, one tissue adhesive) showed a perforation in five cases without any symptoms. This represents 1.7% of all operations of the nasal septum and 7.4% of all recorded mucosal lesions of the nasal septum. Although the number of examinations are still few, it might be justifiable to conclude that one-sided lesions of the nasal septum need no specific therapy. All bilateral corresponding lesions, even those smaller than 5 mm, should be treated by one-sided suture in the anterior septum and with tissue adhesive in the posterior septum. The use of cartilage, bone or fascia alone is insufficient. Large defects of the mucosa should be treated by maximal therapy, i.e. covering with lyophilised fascia or dura, underlaying of cartilage or bone and using tissue adhesive.

Dynamics of eicosanoids in peripheral blood cells during bronchial provocation in aspirin-intolerant asthmatics.

The underlying mechanisms of bronchoconstriction in aspirin-intolerant asthmatics (AIAs) are still unknown, but the hypothesis of an altered metabolism of arachidonic acid is generally accepted. So far, no in vitro test for aspirin intolerance is available. The hypothesis that the profile of eicosanoid mediators is changed in AIA-even before aspirin challenge was tested. The release of prostaglandin E2 (PGE2), peptidoleukotrienes and histamine was measured using competitive enzyme immunoassays in 10 asthmatics with a history of aspirin intolerance, 10 controls and eight aspirin-tolerant asthmatics (ATAs) before and after bronchial provocation with lysine-aspirin. Comparing basal release of eicosanoids before challenge, peptidoleukotrienes were significantly elevated and PGE2 was vastly reduced in AIAs, whereas ATAs had elevated basal peptidoleukotrienes but only slightly reduced basal PGE2. The decrease in forced expiratory volume in one second (FEV1) was not associated with changes in histamine release. After aspirin challenge, there was a massive increase of already elevated peptidoleukotrienes in AIAs, but not in ATAs. Arachidonic acid-induced PGE2 release in AIAs was not significantly changed, whereas it was significantly reduced in ATAs and healthy controls. Histamine release was unaffected by aspirin challenge in all three groups. There is a typically altered profile of eicosanoids in aspirin-intolerant asthmatics which could make in vitro diagnosis of aspirin intolerance possible.

Arachidonic acid metabolism in nasal tissue and peripheral blood cells in aspirin intolerant asthmatics.

Aspirin intolerance (AI) is characterized by polypous rhinosinusitis, bronchial asthma and adverse reactions to aspirin. The common intolerance to all cyclo-oxygenase inhibitors allows us to focus study of the pathogenesis of AI on the metabolism of arachidonic acid (AA). We studied the metabolism of AA in nine aspirin intolerant asthmatics (AIA) and eight healthy volunteers (controls) by measuring prostaglandin E2 (PGE2) and peptido-leukotrienes (pLT = LTC4/D4/E4) in nasal tissue and peripheral blood cells (PBCs) using a specific immunoassay. In all patients with AI the tests were performed before and after bronchial provocation with lysine-ASA. In the control group the tests were done before and after 500 mg ASA p.o. The release of pLT in nasal polyps of AIA was found to be significantly higher than in normal mucosa of AIAs and controls. In every tissue a significant increase of pLT after aspirin challenge was observed. Nasal polyps of AIA show a significantly lower release of PGE2 than normal mucosa of AIAs and controls. Peripheral blood cells of AIA show a significantly higher release of pLT and a significantly lower release of PGE2 than PBCs of controls. Therefore clinical manifestations of AI may be based on an alteration of AA metabolism in AIA.

[Clinico-anatomic study of the spina nasalis ossis frontalis and its role within the scope of frontal sinus surgical approach]. / Klinisch-anatomische Untersuchung zur Spina nasalis ossis frontalis und ihrer Rolle im Rahmen der endonasalen Stirnhöhleneröffnung.

BACKGROUND: During endonasal frontal sinusotomy using the sharp spoon (endonasal frontal sinus surgery type II according to Draf or May and Schaitkin) a solid piece of bone is frequently encountered anterior to the neo-ostium. This bone may be referred to as a "nasal spine". A prominent spine may render a sinusotomy difficult or even impossible. METHODS: A maximum endonasal frontal sinusotomy was performed on 36 anatomical specimens by means of a sharp spoon producing neo-ostia of 7 x 5 mm on average. The dimensions of the remaining nasal spine were measured subsequently together with the diameter of the inferior frontal sinus, the thickness of the anterior frontal sinus wall, and the distance from the neoostium to the anterior ethmoidal artery. RESULTS: Almost every specimen (97%) showed a relevant nasal spine. The average height of the spine was 10 mm. The anterior-posterior dimension was 6 mm on average. A correlation was found between the nasofrontal angle and the a.-p. dimension of the spine: the more acute the angle, the thicker the spine was. In three out of four specimens the neo-ostium was separated by just one anterior ethmoidal cell from the anterior ethmoidal artery. CONCLUSIONS: In the majority of the specimens a sufficient endonasal approach to the frontal sinus could be obtained by enlarging the natural ostium as described by Draf or May and Schaitkin. The anterior ethmoidal artery is a valuable landmark for locating the ostium. The maximum diameter of the frontal sinus approach in frontal direction can be estimated by measuring of the nasofrontal angle.

Influence of endoscopic sinus surgery on voice quality.

Twenty-one patients with documented chronic paranasal sinusitis and in need of endoscopic endonasal sinus surgery were subjected to voice analysis. Tape recordings of different sustained vowels were performed pre- and postoperatively. All voice samples were examined with a sound spectrographic analysis system. Patients having known nasal obstruction detected by active anterior rhinomanometry were excluded from further study. Analysis of pre- and postoperative spectrograms focused on changes in center frequency or bandwidth of the first four formants, as well as variations in specific differences of the formant frequencies and amplitudes. The different subgroups of patients revealed a series of significant changes in the parameters studied. The vowels [a:] and [i:] showed inverse changes in measured values, while evaluation of the vowel [u:] was restricted due to artifactual scattering of individual values. In general, band-width diminished and energy peaks of formants increased postoperatively. In 6 of 21 patients (approximately one-third of the cases), patients or other individuals detected perceptual changes of speech postoperatively. Based on our data, we recommend informing all patients, and voice professionals in particular, about the possible effects of endonasal sinus surgery on altering speech.

Endonasal endoscopic surgery for rhinogen intraorbital abscess: a report of six cases.

Intraorbital abscess is a serious complication of sinusitis with the danger of permanent loss of vision and even the danger of life-threatening progress. The recommended surgical procedure in the literature for drainage of an intraorbital abscess is the external approach. We report on successful functional endonasal endoscopic surgery in a series of six sequential cases with intraorbital abscesses following sinusitis. The main advantages of this approach are the simultaneous treatment of causative disorders with surgery following the pathogenic route of the abscess formation and lack of trauma to further structures. The endoscope with 25- or 70-degree angled axis of vision enables the surgeon to explore and drain the abscess cavity, which often is located behind the bulbus, with minimal trauma. For the trained surgeon the field of vision is favorable as compared with the external approach when the abscess is located right in the axis of vision and one has to cut through healthy tissue and the intact skin, which, especially in children, can lead to long-lasting visible scars.

[Pneumatic intracorporeal lithotripsy of salivary calculi. In vitro and animal experiment studies]. / Pneumatische intra-korporale Lithotripsie von Speichelsteinen. In-vitro- und tierexperimentelle Untersuchungen.

BACKGROUND: The effort to use minimally invasive strategies in the treatment of human sialolithiasis in principle seems to allow the clinical application of pneumatic lithotripsy because of the small diameters of the probes involved. While this kind of therapy is already used successfully in urology, we investigated the method during in vitro and animal experiments. MATERIALS AND METHODS: The treatment of stones and tissue utilized the pneumatic lithotripter "Lithoclast". This system works with ballistic energy and is similar to a biologic "pneumatic hammer". Thirty salivary calculi were treated with pneumatic lithotripsy. Four submandibular salivary glands and their ducts were removed intraoperatively and were exposed to the pneumatic probes. Moreover, in two cases a salivary concretion was also implanted prior to pneumatic lithotripsy. In two rabbits the ducts of the parotid glands were ligated for 2 weeks. On the basis of the in vitro experiments, concretions were placed in two of the four salivary ducts. Following this, the pneumatic probes were inserted along the ducts and lithotripsy was completed. RESULTS: All of the 30 salivary calculi were reduced to sizes smaller than 1.5 mm in diameter. No macroscopic or microscopic damage was detectable while the probe was in a duct. However, in both cases with implanted calculi retropulsion of fragments occurred consequent perforation of the ducts. After application of ballistic pulses along the duct, small periductal hematoma without any perforation were detected macroscopically. Microscopically, only small bleeding was observed along the submucosa and partial loss of epithelium was found. In contrast, the pulse application to the implanted concretions lead to destruction of the calculi with perforation of the ducts as well as hemorrhage in the surrounding tissue. CONCLUSIONS: The method of pneumatic lithotripsy used in the present study resulted in sufficient destruction of salivary calculi. In vitro and in vivo lithotripsy of duct implanted calculi led to perforation of the salivary duct in all cases. Because of these results, the clinical use of this technique to treat human sialolithiasis appears to be not justified.

[Fracture healing of the ethmoid bone--a contribution to rhinologic management of naso-ethmoid injuries]. / Untersuchungen zur Frakturheilung im Siebbein--Ein Beitrag zur rhinologischen Versorgung nasoethmoidaler Verletzungen.

Severe maxillofacial trauma accompanied by a dislocated ethmoidal bone fracture was confirmed by CT imaging in 15 adult patients. Routine surgical management included reduction of fractures, miniplate fixation and/or intermaxillary fixation with interosseous wiring. The fractured ethmoidal cell system was left to heal spontaneously. A follow-up examination including endoscopy of the nasal cavity as well as active anterior rhinomanometry and computed tomography was carried out approximately 24 months after surgery. The fractured ethmoidal cell system showed a clear tendency to spontaneously reventilate and drain. However, in 8 of 30 sides a traumatic obstruction of the anterior ethmoid led to secondary frontal sinus mucositis. 12 out of 30 maxillary sinuses ranged from marked mucosal swelling to the development of a traumatic mucocele. Altogether, 9 of the 15 patients suffered from paranasal sinusitis. Routine debridement of every fractured ethmoidal cell system does not appear to be necessary. In case of fractures of the anterior ethmoid with probable obstruction of the nasofrontal duct and/or maxillary sinus ostium, endonasal endoscopic surgery is recommended for minimally invasive reconstruction of the ventilation and drainage of the frontal and maxillary sinus during primary surgical management. Furthermore, patients with severe naso-orbito-ethmoidal fractures should undergo rhinological follow-up examination including CT-imaging approximately 3 months after surgery.

Indications, technique and results of endonasal endoscopic ethmoidectomy.

Endoscopic ethmoid sinus surgery was introduced in Erlangen in 1976. Posterior-to-anterior ethmoidectomy under the optical control of a 70 degrees telescope with a suction-irrigation handpiece was established for treatment of chronic-diffuse hyperplastic paranasal sinusitis. This technique complements partial resections of the ethmoid. The different procedures are applied depending upon the extent of the disease. The indication for endonasal endoscopic surgery was expanded with practical experience. Diseases of the nasolacrimal duct and the frontal sinus, the frontal skull base as well as the orbita often proved to be accessible for endonasal surgery. A survey of the technical aspects of endoscopic ethmoid surgery and an introduction of the extended range of indications are presented together with the results of each procedure.

[Experimental studies of wound healing in the paranasal sinuses. III. Endoscopy and histology of the surgical area after endonasal ethmoidectomy]. / Experimentelle Untersuchungen zur Wundheilung in den Nasennebenhöhlen. III. Endoskopie und Histologie des Operationsgebietes nach einer endonasalen Siebbeinausräumung.

Twenty two patients underwent standardized endoscopic follow-up for a period 3 months after a partial or complete intranasal ethmoidectomy. 370 endoscopic photographs were taken from the healing ethmoidal wound. After precise documentation of the site of removal, 157 biopsies of the regenerating mucosa were made. The endoscopic appearance of the wound was compared with the histological structure. Endoscopy showed that the process of wound healing of the respiratory mucosa could be subdivided into 4 phases: 1. Hemorrhagic crusting lasting up to 10 days 2. Obstructive lymphatic edema lasting up to 30 days 3. Mesenchymal tissue reaction lasting up to 3 months 4. Scar formation beginning after 3 months. The subdivision of wound healing phases enables the endoscopist to recognize retardation of healing and may lead to a staging of the postoperative therapeutic regime.

[Experimental studies of wound healing in the paranasal sinuses. II. Spontaneous wound healing and drug effects in a standardized wound model]. / Experimentelle Untersuchungen zur Wundheilung in den Nasennebenhöhlen. II. Spontaner Wundschluss und medikamentöse Effekte im standardisierten Wundmodell.

A model of wound healing in the maxillary antrum of the rabbit was developed. The regeneration of standardized circular mucosal defects 4 mm in diameter was studied using conventional histology and serial sections as well as three-dimensional histomorphological analysis. Wound closure started by migration of epithelium; 24 h later mitoses were seen. 120 h after creation of the wound the granulation tissue covering the wound surface started to become hyperplastic, and bone apposition with formation of osteoid occurred. Systemic application of prednisolone i.m. (2 mg/kg per day) and topical administration of dexpanthenol-ointment (5%) resulted in an acceleration of the late epithelial wound closure together with a reduction of hyperplastic granulation tissue. Epidermal growth factor, applied locally, had no significant effect. The proposed animal model permits additional quantitative evaluation of postoperative treatment modalities.

[Experimental studies of wound healing in the paranasal sinuses. I. A model of respiratory wounds in the rabbit maxillary sinus]. / Experimentelle Untersuchungen zur Wundheilung in den Nasennebenhöhlen. I. Ein Modell respiratorischer Wunden in der Kaninchenkieferhöhle.

We present an animal model in rabbits for the investigation of normal wound healing in the paranasal sinuses. The blood and lymphatic stream and the mucociliary pathways are demonstrated on the medial maxillary sinus wall to study the influence on wound geometry. Standardized and circular wounds are created in the same area exposing the underlying bone of the maxillary sinus. Using a computer aided system for 3-D-reconstruction, it can be shown that respiratory wound closure is independent of the stream of blood, lymph or mucus. The circular wound diminishes in size concentrically. The standardized wound model may be suitable for comparison of different therapeutic methods of wound care.

Normal wound healing of the paranasal sinuses: clinical and experimental investigations.

Twenty-two patients underwent partial or complete ethmoidectomies and were subjected to standardized postoperative follow-ups including endoscopic photography of healing tissues. Sequential biopsies were also taken from the regenerating mucosa and compared with endoscopic findings. On this basis wound healing could be divided into four different phases, allowing for the diagnosis of healing disturbances and clinical planning of stage-dependent therapy. Additionally, a model of wound healing in the maxillary antrum of the rabbit was developed for better understanding the clinical observations. Regeneration of standardized mucosal defects was studied with three-dimensional histomorphological analysis. Circular wounds were found to regenerate concentrically, with wound closure starting by epithelial migration. Within 120 h, granulation tissue covering the wound surface started to become hyperplastic and bone apposition occurred with the formation of osteoid. The systemic application of prednisolone (2 mg/kg per day i.m.) and topical 5% dexpanthenol ointment resulted in an acceleration of late epithelial wound closure together with a reduction in hyperplastic granulation tissue. Local applications of "epidermal growth factor" had no significant effect.