Lower lip reconstruction with the tongue flap: surgical technique and long-term results.

OBJECTIVE: To demonstrate the functional long-term results after reconstruction of the lower lip with the tongue flap. METHODS: We describe the surgical technique and long-term results of lower lip reconstruction with the tongue flap and review five cases in which this technique was used to reconstruct defects of the lower lip, particularly the lip vermilion. RESULTS: Between 1993 and 2003 we performed reconstruction of the lower lip using the tongue flap in five patients. All patients were followed for 2 to 10 years (mean 3.4 years). The procedure achieved good functional and aesthetic results, with no major complications, in particular no flap necrosis. One patient complained of paresthesias of the tongue which resolved within 24 months. Speech was unaffected by use of the tongue flap, although eating and drinking were temporarily impaired prior to the flap separation at the second and final stage of surgery. CONCLUSION: The tongue flap is a simple and reliable technique for reconstruction of part or all of the lip vermilion. The technique is easy to perform and provides good aesthetic and functional results.

[Endonasal micro-endoscopic resection of sinonasal inverted papilloma]. / Endonasale mikro-endoskopische Resektion invertierter Papillome der Nase und ihrer Nebenhöhlen.

BACKGROUND: The goal of this study was to assess the potentials and limitations of endonasal micro-endoscopic surgery in the treatment of sinonasal inverted papilloma (IP) and to demonstrate long-term results. PATIENTS AND METHODS: From 1989 to 2005, 64 patients underwent resection of IP via an endonasal approach using either the endoscope or microscope. Charts were reviewed retrospectively for presenting symptoms, radiological and intraoperative data. All patients were followed by endoscopic and MRI control during a period of up to 174 months, median follow-up was 78 months. RESULTS: Our study group consisted of 26 male and 38 female patients with an average age of 54.3 years. The majority of the patients (67 %) complained of unilateral nasal obstruction. 52 patients (81 %) were referred for primary surgery. In 12 cases (19 %) recurrent tumors were operated. According to the Krouse classification for IP the tumors were staged as T1 = 11 (17 %) cases, T2 = 37 (58 %) and T3 = 14 (22 %). In two patients a squamous cell carcinoma was associated with an IP ( = T4 stage). Most tumors were localized within the nasal cavity (72 %) or the anterior ethmoid (62 %). In 10 patients an infiltration of the bony skull base was present. During the follow-up period 6 patients developed recurrencies corresponding to an overall recurrence rate of 9.4 %. CONCLUSIONS: The advances in endonasal micro-endoscopic surgery allow both safe and effective removal of IP with low morbidity, and therefore it should be the approach of the first choice. The osteoplastic approach combined with endonasal surgery is suitable in far lateral located IP. Close follow-up is mandatory to ensure the surgical success.

[Paraganglioma of the head and neck--tumor control, functional results and quality of life]. / Paragangliome des Kopf-Hals-Bereiches--Tumorkontrolle, funktionelle Ergebnisse und Lebensqualität nach Operation.

BACKGROUND: Surgical therapy for paragangliomas (PG) of the head and neck is, due to the alternatives of radiation therapy and wait-and-scan strategy and because of postoperative morbidity, under ongoing discussion. MATERIAL AND METHODS: Between 1981 and 2004, 79 patients with 94 PG of the head and neck were treated at our department. These patients had follow-up examination within a clinical trial considering tumor control, functional results and for the first time neuropsychologically evaluated postoperative quality of life. Mean follow-up time was 65 months (1 to 228 months). RESULTS: Among the 94 PG there were 19 carotid body (GCP), 12 vagal nerve (GVP) and 63 jugular-tympanal paragangliomas (JTP). Of these, 87 tumors underwent surgery. In 68 patients (78.1 %), the tumor could be removed completely. In particular, complete resection of GCP was achieved in 100 %, of GVP in 90.9 %, of JTP type A in 100 %, of JTP type B in 83.3 %, of JTP type C in 66.6 % and of JTP type D in 61.5 %. During the follow-up period, residual or recurrent tumors were diagnosed in 17 patients (19.5 %). Six of the seven residual PG were observed by magnetic resonance tomography and did not show growth. One residual PG and 6 recurrencies were resected completely. One recurrent tumor was radiated and 3 others are under observation without showing growth tendencies. Two patients died postoperatively due to borderline operations of extended tumors. The quality of life after PG surgery showed a SIP of 4.8, which is comparably much better than after acoustic neuroma surgery (SIP 10.3). CONCLUSION: Whereas complete tumor resection of GCP and JTP types A and B is almost ever possible without cranial nerve palsies, surgery of GVP and advanced JTP causes often severe functional deficits. However, postoperative quality of life is mostly good. Nevertheless, advanced PG require an individualized therapeutic regime also including radiation and observation of tumor growth.

[Functional results, cognitive and effective quality of life disturbances after trans-temporal resection of acoustic neuroma]. / Funktionelle Ergebnisse, Lebensqualität, kognitive und affektive Konsequenzen nach transtemporaler Exstirpation von Akustikusneurinomen.

BACKGROUND: The aim of the study was to evaluate postoperative hearing, facial nerve function, quality of life (QOL), affective status and neuropsychological performance after trans-temporal removal of acoustic neuromas (AN). PATIENTS AND METHODS: A retrospective analysis was carried out in 89 patients with AN who were operated at the ENT-Department of the Hospital Fulda between 1988 and 2004. Median follow up was 57 months. Of these 41 patients were additionally examined by a psychologist for evaluation of QOL, neuropsychological functions and affective disorders using several questionnaires. RESULTS: The AN were classified as follows: Type A = 53 %, type B = 35 % and type C = 12 %. One year postoperatively facial nerve function was excellent in 93.3 % of the patients (grade I and II). In 53 % of cases hearing could be preserved. The subjective QOL was expressed through depression and social withdrawal associated with deafness. However, facial nerve dysfunction did not lead to QOL effect. Objective QOL (functional level) was reduced because of verbal memory disturbances and symptoms like dizziness. In 47.5 % of the patients affective and/or neuropsychological dysfunctions were diagnosed. Subsequent MRI evaluation showed lesions of the temporal lobe in 40.5 % of the cases. Of these 80 % suffered from cognitive and/or affective disturbances. CONCLUSIONS: The cognitive and affective disturbances after trans-temporal removal of AN could be to a certain degree due to the elevation of the temporal lobe during surgery. Further research, especially pre- and postoperative examination of QOL and psychological state as well as the comparison between different approaches, particularly trans-temporal vs suboccipital have to clear up specific morbidity of the different approaches.

[Clear cell chondrosarcoma of the larynx. A rare tumor in an uncommon location]. / Klarzellchondrosarkom des Larynx. Ein sehr seltener Tumor in einer aussergewöhnlichen Lokalisation.

Clear cell chondrosarcoma is a rare bone tumor of low malignancy. It constitutes only 2% of all chondrosarcomas and shows a particular predilection for the epiphyses of long bones. So far, there have only been three cases of clear cell chondrosarcoma of the larynx published in the literature. We report the case of a 46 year old man who suffered from slowly worsening dyspnoea. Diagnostic evaluation revealed a directly subglottic stenosis of the larynx, narrowing the lumen to 1/3. When we tried to resect the stenosis via splitting the ring cartilage from outside, tumorous infiltration of the whole ring cartilage was found. Extended biopsies were taken and histology revealed a clear cell chondrosarcoma. The therapy of choice for this tumor is wide surgical resection. Additional radio- and/or chemotherapy are not recommended. Therefore, the patient underwent laryngectomy. Histologically, the clear cell chondrosarcoma can be easily confused with the highly malignant osteosarcoma or the conventional chondrosarcoma, both requiring more aggressive treatment. Thus, clear cell chondrosarcoma should be kept in mind and, when necessary, a reference histology by a bone tumor register should be requested.

[Carcinoma of the external auditory canal and middle ear: therapeutic strategy and follow up]. / Therapeutisches Management von Gehörgangs- und Mittelohrkarzinomen.

BACKGROUND: Carcinomas of the external auditory canal (EAC) and the middle ear are rare and considered to have a poor prognosis. The recommended therapeutic strategy consists of surgical excision and postoperative radiotherapy. However, there are different opinions about the extend of the primary operation. PATIENTS AND METHODS: A series of 21 patients with carcinoma of the EAC and middle ear were treated at the ENT-Department of the Hospital Fulda from 1985 to 2003. Their records and radiologic findings were reviewed retrospectively with particular reference to tumor type and size, its relation to surrounding tissues, surgical procedures and radiation techniques. The tumors were staged according to the modified Pittburgh staging system for temporal bone carcinomas. The average follow-up time was 6.2 years (range 0.2 - 18.75). RESULTS: 17 patients suffered from carcinoma of the EAC, 4 carcinomas were primarily located in the middle ear. There were 15 squamous cell carcinomas, 3 adenoidcystic carcinomas, 2 adenocarcinomas and one mucoepidermoid carcinoma. 12 patients came primarily to our institution and were staged as follows: pT1 (n = 2), pT3 (n = 2), pT4 (n = 8). 8 patients showed up with recurrent or residual tumors (all of T3 or T4 stage). One patient could not be classified. In 5 cases the tumor was inoperable. These patients underwent combined chemoradiation therapy. All other 16 patients were operated and most of them received adjuvant radiation therapy. In the group of patients who were primarily operated overall 5-year survival rate was 100 %. In contrast, patients who's recurrent or residual tumors were resected had a 5-year survival rate of only 33 %. Patients who received combined chemoradiation therapy showed a 2-year survival rate of 75 %. CONCLUSION: Carcinoma of the EAC and middle ear should be treated primarily by a lateral or subtotal temporal bone resection stage dependent combined with a parotidectomy as well as a neck dissection. Local resection of the EAC is not sufficient, not even in T1 tumors. As from stage T2, in cases of recurrent tumor removal and questionable free margins as well as in cases with lymph node metastases an adjuvant radiation therapy should be added. The most important survival factor is removal of the primary tumor with histologically clear margins.