Adenoid hypertrophy-​diagnosis and treatment: the new S2k guideline.

Hyperplasia of the pharyngeal tonsils is to be considered pathologic when nasopharyngeal symptoms of mechanical obstruction and/or chronic inflammation occur. Chronic Eustachian tube dysfunction can result in various middle ear diseases such as conductive hearing loss, cholesteatoma, and recurrent acute otitis media. During examination, attention should be paid to the presence of adenoid facies (long face syndrome), with a permanently open mouth and visible tip of the tongue. In the case of severe symptoms and/or failure of conservative treatment, adenoidectomy is usually performed on an outpatient basis. Conventional curettage remains the established standard treatment in Germany. Histologic evaluation is indicated for clinical evidence of mucopolysaccharidoses. Due to the risk of hemorrhage, the preoperative bleeding questionnaire, which is obligatory before every pediatric surgery, is referred to. Recurrence of adenoids is possible despite correct adenoidectomy. Before discharge home, otorhinolaryngologic inspection of the nasopharynx for secondary bleeding should be performed and anesthesiologic clearance obtained.

[Adenoids-diagnosis and treatment: the new German S2k guideline]. / Adenoide Vegetationen ­ Diagnostik und Therapie ­ die neue S2k-Leitlinie.

Hyperplasia of the pharyngeal tonsils is to be considered pathologic when nasopharyngeal symptoms of mechanical obstruction and/or chronic inflammation occur. Chronic Eustachian tube dysfunction can result in various middle ear diseases such as conductive hearing loss, cholesteatoma, and recurrent acute otitis media. During examination, attention should be paid to the presence of adenoid facies (long face syndrome), with a permanently open mouth and visible tip of the tongue. In the case of severe symptoms and/or failure of conservative treatment, adenoidectomy is usually performed on an outpatient basis. Conventional curettage remains the established standard treatment in Germany. Histologic evaluation is indicated for clinical evidence of mucopolysaccharidoses. Due to the risk of hemorrhage, the preoperative bleeding questionnaire, which is obligatory before every pediatric surgery, is referred to. Recurrence of adenoids is possible despite correct adenoidectomy. Before discharge home, otorhinolaryngologic inspection of the nasopharynx for secondary bleeding should be performed and anesthesiologic clearance obtained.

Evaluation of the efficacy of the 'nasal airflow-inducing manoeuvre' for smell rehabilitation in laryngectomees by means of the Sniffin' Sticks test.

OBJECTIVE: To determine the efficacy of the nasal airflow-inducing manoeuvre (NAIM) as a method for olfactory rehabilitation in laryngectomees by the means of the Sniffin' Sticks test. STUDY DESIGN: Prospective open interventional trial. SETTING: Tertiary academic hospital. PARTICIPANTS: Thirty-seven patients after laryngectomy have been screened and 25 patients have been included into the study. The participant's sense of smell was tested with the Sniffin' Sticks test before and after learning the nasal airflow inducing manoeuvre. The individual level of threshold, discrimination and identification (TDI) was determined and the individual threshold, discrimination and identification score was used to classify the patients as being anosmic, hyposmic or normosmic. MAIN OUTCOME MEASURES: The primary endpoint was the change of the threshold, discrimination and identification score before and after learning the nasal airflow inducing manoeuvre. The secondary endpoint was a change in the diagnostic group (normosmic, hyposmic and anosmic) after learning of the nasal airflow inducing manoeuvre. RESULTS: There was a statistically significant increase in the total threshold, discrimination and identification score (P < 0.001) and the three sub-scores (P ≤ 0.02) before and after the learning of the nasal airflow inducing manoeuvre. Patients gained seven points on average in the threshold, discrimination and identification score. Twenty of 25 patients showed an increase of five or more point in the threshold, discrimination and identification score. In the classification of the smell ability, 15 of 25 patients showed a change to a higher class (hyposmic to normosmic or from anosmic to hyposmic or normosmic). CONCLUSION: The nasal airflow inducing manoeuvre is a method for the successful rehabilitation of the sense of smell in laryngectomees. The evaluation with the Sniffin' Sticks tests showed a clinically relevant increase of olfaction in 80% of patients. The teaching of the nasal airflow inducing manoeuvre should be included in post-laryngectomy rehabilitation programmes.

Recurrence of a laryngeal spindle cell sarcoma with a transformation into a higher grade of malignancy.

Primary malignant mesenchymal neoplasms of the larynx are rare. Sarcomas of the larynx account for <1% of all malignant laryngeal mesenchymal neoplasms. This report examines a case of a recurring laryngeal, initial benign-appearing mesenchymal tumour, which first changed its clinical phenotype without any histological signs of malignancy and later also its histological appearance with signs of malignancy. Finally, it even underwent a transformation into a higher grade of malignancy. In addition to this, the difficulties of allocating this tumour to the correct sarcoma subentity are shown.

Multifocal adult rhabdomyoma of the head and neck: a case report and literature review.

Adult rhabdomyoma is a rare, usually solitary, primary tumour of striated muscle origin that almost exclusively presents in the head and neck region with predilection for male. We herein present a rare case of a multifocal adult rhabdomyoma in a 72-year-old woman. The lesions were located, the first one in the area of the left aryepiglottic fold and the second one right cervical arising from oesophagus. The diagnosis of the cervical mass was obtained prior to resection through cytological examination (FNAC). We discuss the clinical, cytological and histological findings and we provide a brief review of the literature on this entity.

[Extraesophageal reflux in patients suffering from Zenker's diverticulum]. / Extraösophagealer Reflux und Zenker-Divertikel.

INTRODUCTION: Patients with Zenker's diverticulum often present with a hiatal hernia. Theoretically, the gastric acid fluid could rise up to the hypopharynx producing an injury to the mucosa of Killian's triangle and hypertrophy of the cricopharyngeal muscle. We performed dual-channel pH monitoring in healthy people as a control group and in patients with a Zenker's diverticulum to elucidate the relationship between Zenker's diverticulum and gastroesophageal reflux disease (GERD) as well as extraesophageal reflux (EER). METHODS: Patients with Zenker's diverticulum underwent dual-channel 24-h pH monitoring to exclude the possibility of an EER or a GERD. The measurements were performed in 4 patients preoperatively and postoperatively as well as in 14 patients only postoperatively. The control group consisted of healthy volunteers who did not suffer from a reflux disease (n=20). In each group we determined the number of refluxes, the fraction time, the RAI (reflux area index), and the DeMeester Score Index. In addition we classified the severity of the EER with a grading system which was developed in an earlier study in our department. RESULTS: Patients with a Zenker's diverticulum suffered significantly from EER (p<0.01). The difference between the patients measured preoperatively and the patients postoperatively was minor. More than 72% of the patients suffered from a severe EER. CONCLUSIONS: Patients with a Zenker's diverticulum have a high possibility of suffering from EER and GERD. The pathophysiology of this relationship can only be speculated. In addition to a cricopharyngeal myotomy, long-term therapy with a PPI (proton pump inhibitor) seems indicated.

[Nutrition in patients with head and neck cancer]. / Ernährung bei Patienten mit Kopf-Hals-Tumoren.

Nutrition in Patients with Head and Neck Cancer. Malnutrition is common in patients with head and neck cancer. Due to natural course of disease or therapy, malnutrition may increase. This leads to a reduced prognosis, quality of life, and should be considered in early stages of the disease. First choice is an enteral feeding via a nasogastral feeding tube or a PEG. In special cases a parenteral nutrition may be necessary.

Selective high-dose intra-arterial cisplatin as palliative treatment for incurable head and neck cancer.

OBJECTIVE: The purpose of the present study was to evaluate the palliative effect of selective intra-arterial chemotherapy in progressive unresectable head and neck cancer previously treated with radiochemotherapy. PATIENTS AND METHODS: 8 patients with advanced residual or recurrent squamous cell carcinoma of the head and neck were evaluated. These patients were included in the present study particularly because of progredient pain and recurrent bleedings due to tumor progression. In addition 6/8 patients suffered from unpleasant tumor-related smell. All patients received simultaneous infusions of cisplatin (150 mg/m2) intra-arterially to the tumor and sodium thiosulfate intravenously (9 g/m2) for systemic neutralization of cisplatin. The patients were treated by at most 4 cycles of selective intra-arterial chemotherapy via femoral approach. RESULTS: Tumor-associated pain, occurrence of tumor bleeding and tumor-related smell were reduced after at least 2 cycles of intra-arterial chemotherapy in all patients. Clinical and radiological assessment of the primary tumor site revealed a partial response in 4 patients while 4 patients were classified as nonresponders. Intra-arterial cisplatin treatment was well tolerated. CONCLUSION: Selective intra-arterial cisplatin therapy can be delivered safely for palliation of tumor-related symptoms of incurable head and neck cancer.

Differential regulation of MAPK (JNK 3) gene expression in human head and neck squamous cell carcinomas.

BACKGROUND: The JNK 3 gene encodes a protein which belongs to the mitogen-activated protein (MAP) kinases, a group of molecules involved in signaling pathways. MATERIAL AND METHODS: Messenger RNA extracted from head and neck squamous cell carcinoma (HNSCC) cells and normal upper aerodigestive tract mucosa keratinocytes was reversely transcribed. The resulting cDNA populations were subjected to an arbitrarily primed mRNA fingerprint. After electrophoresis, the band pattern was detected by autoradiography. RESULTS: A 107 bp mRNA fragment was detected in HNSCC cells showing considerable repression in comparison with the benign phenotype. After cloning of this fragment, a database search revealed an exact homology with sequences belonging to the c-jun N-terminal MAP-10 kinase (JNK 3). Northern hybridization confirmed the distinctly reduced expression of this gene in HNSCC biopsies in contrast to adjacent normal mucosa. CONCLUSION: The results show evidence that the expression of the JNK 3 gene is strongly repressed, suggesting that JNK 3 is implicated in carcinogenic processes in head and neck cancer.

Photodynamic effects of anthracyclin derivatives on squamous cell carcinoma cell lines of the head and neck.

BACKGROUND AND OBJECTIVE: In the last years, photodynamic therapy, performed with hematoporphyrin derivatives, gained in importance for the treatment of superficially situated malignomas. The use of hematoporphyrin as photosensitizer is limited especially by the low depth of penetration and its side effects. The aim of the present study was to evaluate the effectiveness of photodynamic therapy with anthracyclin derivates in squamous cell carcinoma cell lines. STUDY DESIGN/MATERIALS AND METHODS: The photodynamic effects of the anthracyclin derivates adriamycin and epirubicin as well as the effects of the hematoporphyrin derivatives photofrin-II and photosan-3 were examined and compared in 10 squamous cell carcinoma cell lines derived from head and neck tumors. RESULTS: Beside their cytostatic effect, the applied cytostatics revealed a marked photodynamic effect. A statistically significant difference for photodynamic effects of both cytostatic agents and the hematoporphyrin derivates could not be shown. CONCLUSIONS: These results revealed that the above mentioned cytostatics could be considered as possible alternative photosensitizer for photodynamic therapy.

Bilateral congenital dacryocystocele as a cause of respiratory distress in a newborn.

Newborns with respiratory distress and nasal obstruction must be examined for congenital dacryocystocele. This disease is caused by a stenosis in the proximal and distal area of the nasolacrimal duct and leads to a cystic dilatation of this duct. A case of a newborn with bilateral dacryocystocele and dyspnoea is presented. The otorhinolaryngologic as well as the paediatric examination could only reveal in the rhinoscopic examination a tumor of the left nasal cavity that partly obstructed the endonasal space. No other pathologic findings were detected. To clarify the origin and the localization of the tumor as well as to exclude an intracranial relation, a magnetic resonance imaging of the middle face and the frontal skull base was performed. After probe and rinsing of the lacrimal ducts the symptoms improved rapidly. In newborns with nasal obstruction a bilateral rhinoscopy of the lower nasal meatus is required to exclude the existence of a dacryocystocele.

[Sonographic features of a submandibular epidermoid cyst]. / Sonographische Aspekte einer submandibulär lokalisierten Epidermoidzyste.

We present the case of a 23-year-old man with a few weeks history of a gradually enlarging mass of the right submandibular region. On palpation, the well-defined swelling had an engorged and elastic consistency. Sonography revealed a sharply defined mass with spherical and solid echorich lesions surrounded by areas of liquid. Histological examination of the resected tumour revealed an epidermoid cyst. The wall of the cyst was composed of stratified squamous epithelium with the cystic space containing keratin arranged in layers. Characteristic sonographic findings of epidermoid cysts regularly permit accurate preoperative diagnosis without the need for additional imaging procedures.

Atypical mycobacterial tuberculosis--a diagnostic and therapeutic dilemma? Case reports and review of the literature.

In immunocompetent preschool children cervical lymphadenitis is a common clinical presentation of atypical mycobacteria. Its rapid diagnosis and treatment is still a challenge, because accurate diagnostic procedures for atypical mycobacteria are still not yet available in routine practice. Two children suffered from craniojugular (16 months old girl) and infraauricular (2.5 years old boy) located neck masses which showed resistance to the medical treatment. In the first case an abscess splitting took place initially, followed by an anti-tubercular drug treatment and necessary surgical reintervention. In the second case surgical removal of all involved lymph nodes, infiltrated surrounding soft tissue and involved skin areas were followed by medical treatment. In both cases presumed infection with mycobacterium tuberculosis was not confirmed, but atypical mycobacteria could be isolated both. In the first case atypical mycobacterium could be specified as mycobacterium avium complex and in the second case as mycobacterium malmoense. Both bacilli showed sensitivity towards medical treatment with clarithromycin, whereby in one case only the surgical reintervention led to a complete removal of clinical symptomatic. In cases of presumed tuberculous neck lymph node infections differential diagnosis of an atypical mycobacterial lymphadenitis should always be supposed, because medical and surgical treatment differ fundamentally.

Lymph node topography of the head and neck in New Zealand White rabbits.

Investigations of the lymphogenic metastatic spread of VX2 carcinomas in New Zealand White rabbits require an exact knowledge of the topography of cervical and facial lymph nodes. The topography of neck lymph nodes was evaluated from 16 rabbits macroscopically, histologically and by lymphographic investigations, and the possibility of their surgical removal (neck dissection) was examined. The upper aerodigestive tract and the ear of New Zealand White rabbits drain via four consistent groups of 12-18 lymph nodes. Except for the paratracheal lymph node, they are all easily accessible to surgery. The data presented in this study encourage the use of induced VX2 carcinomas in New Zealand White rabbits as an animal model to study the lymphogenic metastatic spread of squamous cell carcinomas of the head and neck. Such investigations could lead to an improvement of surgical and pharmaceutical treatment of this tumour entity.

Coagulation and temperature distribution in Nd: YAG interstitial laser thermotherapy: an in vitro animal study.

Interstitial laser thermotherapy (ILTT) was performed increasingly for local destruction of different tumours. The proposal of the present study was the optimisation of the therapy-relevant ILTT parameters and laser application forms which are a prerequisite for the development of an optimal tumour treatment strategy. Laser-induced temperature changes and coagulation patterns with different laser light applicators (bare fibre, ring mode fibre, side fibre, diffuser fibre) were investigated on liver, spleen and tongue tissues of 26 adult pigs after interstitial thermotherapy with Nd: YAG laser. Analysis of experimental results on ILTT and tissue necrosis showed a dependence on laser exposure time, type of laser fibre and applied laser energy. The most homogeneous and extensive coagulation zone was seen after laser treatment with rather low energy over a longer time period.

Wound healing after laser treatment of oral and oropharyngeal cancer.

The wound healing after laser surgery is delayed in contrast to conventional scalpel surgery. There are some animal studies, which investigated the effects of laser surgery upon wound healing, whereas clinical investigations on wound healing of human mucous membrane after laser surgery is missing. A histological study on the laryngeal mucosa of 11 patients after laser incisions who underwent emergent laser debulking surgery for acute airway obstruction and a clinical study of 24 patients with oral or oropharynx cancer who were treated by laser surgery were performed to investigate the course of wound healing. The histological findings showed that the beginning of wound healing was delayed after laser surgery. The duration of wound healing after laser surgical tumour resection revealed a clear dependence on the size of the initial defect. The average duration of wound healing after CO(2) laser surgery (32.8 +/- 9.2 days) was significantly shorter than after Nd:YAG laser surgery (40.4 +/- 9.2). Due to the more pronounced zone of necrosis at the base of the wound ground this effect is more evident using the Nd:YAG laser. However, the different course of wound healing with both laser systems does not seem to have a negative influence on functional results.

Excretion measurement of porphyrins and their precursors after topical administration of 5-aminolaevulinic acid for fluorescence endoscopy in head and neck cancer.

5-Aminolevulinic acid (5-ALA) is a useful agent to enhance the detection of early epithelial lesions in head and neck cancers. It is applied either topically or systemically and converted intracellular into photosensitive protoporphyrin IX (PpIX). By ultraviolet light illumination malignant and fast proliferating lesions are detected by a characteristic red fluorescence and delineated by the bluish fluorescence of healthy tissue. To assess the elimination patterns 5-ALA, porphobilinogen (PBG) and porphyrin were measured 12h and 36h after administration in urine, 12h and 24h after examination in blood and in feces 12h after endoscopy. 5-ALA was applied either by inhalation (250 mg) or mouth rinse (200 mg). After both administration routes, excretion levels in urine returned to background levels within 12 hours after administration and only in feces values are slightly increased for PpIX and total porphyrin. Concentrations in erythrocytes were elevated, but not in plasma. No side effects were observed. According to our results the topical administration of 5-ALA is a useful method with satisfying fluorescence imaging results. Levels of metabolites in urine and plasma return to normal within 12 hours so that skin photosensitization can be neglected.

Epiglottopexy for the treatment of severe laryngomalacia.

Laryngomalacia is the most common cause of stridor in newborns and infants. Up until now, different surgical techniques for the treatment of this disease have been described. We report on a modified technique, the so called epiglottopexy, which is a laser-surgical treatment strategy in severe laryngomalacia. A total number of six children (ages: 6 weeks-10.4 years) were treated for life-threatening stridor, which was due to an isolated posterior displacement of the epiglottis during inspiration. In two patients, shortened aryepiglottic folds contributed to the stridor. In all of the children, a modified technique of epiglottopexy was performed transorally; in two cases, this was followed by laser surgical transection of the aryepiglottic folds. Epiglottopexy on the base of the tongue was performed using single suture stitches following laser-surgical vaporization of the corresponding mucosal areas of the epiglottis and the base of the tongue. No intra- or postoperative complications were observed. All six children demonstrated significant airway improvement without any further stridor. Deglutation was not impaired. The presented laser-surgical technique seems to be an appropriate therapy for treatment of severe forms of laryngomalacia characterized by an isolated posterior displacement of the epiglottis during inspiration.