[Munchausen syndrome and chronic otitis media]. / Münchhausen-Syndrom und chronische Otitis media.

In this case report an artificial disorder with symptoms of chronic otitis media and progressive hearing loss is described. This represents a rare case of Munchausen syndrome. The difficulties in diagnosis and therapy are shown by the development of the disease, produced by self damaging activities.

[Not all vocal cord failure following thyroid surgery is recurrent paresis due to damage during operation. Statement of the German Interdisciplinary Study Group on Intraoperative Neuromonitoring of Thyroid Surgery concerning recurring paresis due to intubation]. / Nicht jeder Stimmlippenstillstand nach Schilddrüsenoperation ist eine chirurgischbedingte Rekurrensparese. Stellungnahme der "Interdisziplinären Studiengruppe Intraoperatives Neuromonitoring Schilddrüsenchirurgie" zur Problematik intubationsbedingter Rekurrensparesen.

Since the phoniatrician H. Bauer described the first case of recurrent laryngeal nerve palsy most likely caused by intubation some 45 years ago, several case reports have been published. However, systematic analyses regarding the frequency of recurrent laryngeal nerve palsies due to intubation are scarce, and none of them has used the proper methods to demonstrate clearly that such a mechanism exists. Currently available data justify the assumption that not every recurrent laryngeal nerve palsy following thyroid surgery is due to the operation itself and that the damage caused by intubation, however, may only account for a minority of these cases. The differential diagnosis of postoperative recurrent laryngeal nerve palsy requires the use of specific tools which go beyond simple laryngoscopy and include stroboscopy as well as intra- and extralaryngeal electromyography. A partial palsy of recurrent laryngeal nerve due to intubation would be associated with severe dysphonia or aphonia, not with dyspnea because of the typical intermediate position of the paralyzed vocal folds with a normal electromyographic function of the cricothyroid muscle. The use of these methods to identify the nature of postoperative recurrent laryngeal nerve palsy is recommended in cases of regular intraoperative neuromonitoring but postoperatively impaired function of the vocal cords.

[Effectiveness and results of intraoperative neuromonitoring in thyroid surgery. Statement of the Interdisciplinary Study Group on Intraoperative Neuromonitoring of Thyroid Surgery]. / Zuverlässigkeit und Konsequenzen des intraoperativen Neuromonitorings in der Schilddrüsenchirurgie. Stellungnahme der "Interdisziplinären Studiengruppe Intraoperatives Neuromonitoring Schilddrüsenchirurgie"

Intraoperative neuromonitoring (IONM) has yielded an increasing effect on thyroid surgery. During IONM, the recurrent laryngeal nerve is stimulated electrically and an acoustically transformed electromyographic signal is derived via either a needle electrode placed in the vocalis muscle or an electrode adjusted to the intubation tube. The IONM is used for identifying and predicting the function of the recurrent laryngeal nerve. Especially under difficult anatomic conditions, IONM has proven a valuable tool for identification of recurrent laryngeal nerves. This can lead to decreased occurrence of nerve palsy rates, as shown in numerous studies. The reliability of the IONM signal (defined as the correlation between intraoperative signal interpretation and postoperative vocal cord function) is reflected by a specificity as high as 98.2%, as shown by German multicenter studies. Thus, normal vocal cord function could be demonstrated postoperatively in over 98.2% of patients with intraoperatively unchanged neuromonitoring signals. If the neuromonitoring signal changed during operation, 39% of the patients suffered from transient vocal cord immobility and 12% had permanent loss of vocal cord function.

[Intraoperative neurophysiological monitoring (IONM) of the recurrent laryngeal nerve and microdissection. Surgical techniques for decreasing the risk of recurrent laryngeal nerve paralysis]. / Intraoperatives neurophysiologisches Monitoring (IONM) des Nervus recurrens und Mikrodissektion. Operationstechnische Verfahren zur Risikominderung von Recurrensparesen.

BACKGROUND: Frequently numerous recurrent laryngeal nerve injuries occur after operations on the thyroid glands. Compared with postoperative permanent hypocalcemia, unilateral and especially double-side recurrent paresis pose serious complication. As early as 1938 specialists [1] pleaded for a routine visualisation of the nervus recurrens in operations of the thyroid gland, to reduce the risk of permanently recurring paresis. In controversial discussions of the matter specialists have opted for a demonstration of the nerve also under medico-legal aspects. Implementing functionally-critical operational strategies requires the choice of an anatomically suitable operative procedure for the removal of morphological, functional and oncological changes, as well as the avoidance of complications. METHOD: Intra-operative Monitoring is highly recommendable as a neurophysiological method of supervision combined with microdissection to ensure the safe handling of recurrent laryngeal nerve. CONCLUSION: The rate of permanent paresis on the recurrent nerve can be lowered to less than 1 per cent when this is used as a routine procedure for all operations and the treatment of the thyroid gland diseases.

Observations on simultaneous perilymphatic motions and cochlear microphonics suppression.

Very low frequencies interfere in the intact cochlea with higher frequencies and suppress these depending on the vibration phase of the low-frequency sound. Physiological functions of the body, mediated, for example, by the eardrum or perilymph coupling with the cerebrospinal fluid, cause a low-frequency pressure modulation of the perilymph, which generates a synchronous perilymphatic motion resulting from the unevenly distributed compliances in the cochlea. This slow streaming causes a displacement of the entire basilar membrane, with as a consequence a postponement of the operating point of the mechanoelectrical transducer as a result of the pressure drop in the helicotrema and the narrow apical cochlear turn. In this contribution, interference phenomena are described, which are caused by spontaneous contractions of the tensor tympani muscle and by respiration-synchronous perilymphatic flow. These two test signals have trapezoidal and triangular impulse functions. In both cases, as suppression pattern of the cochlear microphonics level-time function, the second derivative of the pressure-time function was observed. The suppression is found to lie between 1 and 2 dB. It depends on the level of the suppressed sound and shows a compressive nonlinearity.

[Keratocysts of the jaws with an expansion to the skull base]. / Keratozysten der Kiefer mit Ausbreitung in die Schädelbasis.

Ceratocysts prefer attaint the jaws solitarily or multiply. Familiar heapings are described in connection with the naevoid basal cell carcinoma syndrome (Gorlin-Goltz-Syndrome). In most of the patients they are removable simply by enucleation. The histological typing as a cyst suggests a harmlessness of the disease. There is a significant higher amount of recurrent cysts compared to other odontogenous cysts, whereas clinical symptoms are absent for a long time. That give reasons for findings of breakthrough to the skull base. There are no real alternatives for the impairing operation procedures. It is reported about 69 patients with ceratocysts. In 6.9% a breakthrough to the skull base was found. Therefore a radical operation procedure and a close meshed postoperative checking management with regular MRI and conventional x-ray will be demanded.

Determination of 1-methylhistamine and 1-methylimidazoleacetic acid in human urine as a tool for the diagnosis of mastocytosis.

The determination of the metabolites of histamine, 1-methylhistamine (MHIS) and 1-methylimidazoleacetic acid (MIIA), in human urine is a useful tool for the diagnosis of mastocytosis. MHIS was extracted under basic conditions with chloroform and derivatized with trifluoroacetic acid anhydride, MIIA was derivatized with pentafluorobenzylbromide prior to extraction under basic conditions and the derivative was extracted with chloroform. The samples were assayed by gas chromatography-mass spectrometry. Normal concentrations of MHIS (2.01 micromol l(-1)) and MIIA (21.3 micromol l(-1)) in healthy volunteers' urine samples are clearly detectable with coefficients of variation of 7.0 and 8.9%. Pathological concentrations of 10.1 and 113 micromol l(-1) for MHIS and MIIA, respectively, are quantifiable with coefficients of variation of 6.6 and 4.8%.

Successful treatment of disseminated facial verrucae with contact immunotherapy.

Disseminated flat warts are a common therapeutic problem in immunocompromised patients. However, disseminated infection on the face is, even in the immunocompetent host, a challenge. We report on a 14-year-old girl who had suffered from increasing eruptions of multiple disseminated verrucae planae et filiformes of the face for 18 months. As an alternative to silk-touch CO2-laser, contact cryotherapy or systemic immune enhancer we administered topical immunotherapy with diphenylcyclopropenone (DCP). The initial challenge with DCP 2% was performed on the forehead and the challenge was repeated weekly with DCP 0.01%. After four applications, the girl reported peeling of single warts on the forehead but more importantly at distant sites which had not received DCP. After eight weeks the patient's face was free of lesions. So far, the patient has remained free from relapse. This is the first case report of successful topical immunotherapy with DCP in disseminated facial verrucae planae and should be regarded as an effective therapeutic tool in this indication, emphasizing the great advantage of prevention of scarring of the skin induced by other therapeutic modalities.

[Craniofacial abnormalities in the Charité Virchow Collection]. / Kraniofaziale Fehlbildungen in der Virchow-Sammlung der Charité.

On 27 June 1899 Rudolf Virchow (1821-1902) inaugurated the Museum of Pathology at the Charité Hospital. The collection comprised 23,500 pathologic-anatomical specimens. Most of the collection was destroyed in World War II. About 2000 samples were saved. Meanwhile the stock has increased to about 9000 objects. The development, contents and structure of the famous Virchow Collection are described with special reference to craniofacial deformities.

[Natural coral calcium carbonate as alternative substitute in bone defects of the skull]. / Natürliches korallines Kalziumkarbonat als alternativer Ersatz bei knöchernen Defekten des Schädels.

A biomaterial derived from natural corals with surgical applications is the calcium carbonate Biocoral. Since 1992 the author has been using this material as a bone graft substitute in maxillofacial surgery. Eighty-nine clinical implantations were done in 68 patients for different indications. The results suggested that coral grafts are well tolerated and are simultaneously partially ossified as the calcified skeleton is resorbed. Clinical cases show that use of this material has been successful.

[Craniofacial deformities in the Virchow Collection at the Charité Hosptial]. / Kraniofaziale Fehlbildungen in der Virchow-Sammlung der Charité

On 27 June 1899 Rudolf Virchow (1821-1902) inaugurated the Museum of Pathology at the Charité Hospital. The collection comprised 23 500 pathologic-anatomical specimens. Most of the collection was destroyed in World War II. About 2000 samples were saved. Meanwhile the stock has increased to about 9000 objects. The development, contents and structure of the famous Virchow Collection are described with special reference to craniofacial deformities.

[Intraoperative neuromonitoring of the recurrent laryngeal nerve--routine use in thyroid gland surgery]. / Intraoperatives Neuromonitoring des Nervus laryngeus recurrens--routinemässiger Einsatz in der Schilddrüsenchirurgie.

We present a simple and reliable method for identification of the recurrent nerve by intraoperative stimulation. An electromyographic record from the vocal muscle is obtained using a bipolar needle electrode inserted through the cricothyroid membrane. The recurrent nerve could be easily identified in 176 cases out of 181 nerves at risk (97.2%). We have not seen any cases of recurrent nerve paralysis and discuss the advantages of intraoperative neuromonitoring as a routine procedure.

Radiographic manifestations of multiple myeloma in the mandible: a retrospective study of 77 patients.

PURPOSE: This retrospective study was done to determine the frequency and radiographic pattern multiple myeloma in the mandible. PATIENTS AND METHODS: Seventy-seven patients with multiple myeloma were studied using skull and panoramic radiographs of the jaws made at the time of initial diagnosis. RESULTS: Skull manifestations were present in 46.7% and jaw manifestations in 15.6% of the cases studied. The pattern of jaw involvement was characterized by osteolytic lesions without other radiographic manifestations of bone involvement. There was no relationship between the pattern of jaw and extragnathic involvement and increased M-component of secreted immune globulin. Jaw involvement was largely unaccompained by oral symptoms. CONCLUSION: The results suggest that mandibular lesions are a common finding in multiple myeloma.

Radical surgery (R2 resection) for gastric cancer. A multivariate analysis.

BACKGROUND: Extended lymphadenectomy remains controversial in the Western world. Its evaluation and the identification of high-risk patients after surgery are important tasks. METHODS: A retrospective prognostic study of 318 patients treated for potential cure of gastric cancer was performed. All patients underwent extended lymphadenectomy. Clinical histopathologic and surgical factors were examined for their influence on survival by univariate and multivariate analysis. RESULTS: Postoperative mortality was 4.4% (14 of 318), and the 5-year adjusted survival rate was 57.8%. Multivariate analysis using the Cox model identified seven factors as having independent influence on survival. Detrimental factors were male gender, age over 65 years, high pN category, increasing number of lymph nodes invaded by metastases, total gastric resection, splenectomy, and increasing number of perioperatively required blood units. CONCLUSION: Extended lymphadenectomy was possible without sacrificing low postoperative mortality rates. The importance of certain prognostic factors, in particular lymph node status, could be confirmed.

Transfusion results of cytapheresis platelet concentrates stored in two different polyolefin containers for five days.

OBJECTIVE: Two different types of polyolefin storage containers were compared in order to estimate their ability to preserve apheresis platelet concentrates for 5 days. MATERIAL AND METHODS: Ten pairs each consisting of one patient with thrombocytopenia following chemotherapy and one healthy platelet apheresis donor were examined. The platelet concentrates stored in the LE-2 bag were collected with a Fresenius AS 104 cell separator and those stored in the PL 732 with a Fenwal CS 3000. RESULTS: The separation efficiency of both cell separators was similar; the mean yields were 3.37 +/- 0.83 x 10(11) platelets in 274 +/- 26 ml for the AS 104 and 3.87 +/- 1.31 x 10(11) platelets in 318 +/- 22 ml for the CS 3000 (mean +/- SD). Storage for 5 days did not influence the platelet count significantly. The platelet loss due to filtration was 16 and 13%, respectively. The mean platelet volume obtained with both systems was reduced from a mean of 8.4 fl immediately after harvesting to 7.6 fl after storage (p < 0.0001) and to 7.3 fl after filtration (p = 0.001). The established corrected count increments (CCI) and the pre- and posttransfusion platelet counts were satisfactory and comparable for the 2 systems tested. The mean CCI of the AS 104-LE-2 system was 14.5 1 h and 7.4 x 10(9) platelets 24 h after transfusion, the mean CCI of the CS 3000-PL 732 system was 12.5 and 5.2 x 10(9) platelets, respectively. CONCLUSIONS: Single-donor apheresis concentrates with a large platelet content may be stored in the new LE-2 polyolefin container for up to 5 days and used in clinical transfusion.

Phonemic structures of delayed phonological systems.

The phonemic inventories of 30 children (aged 3;4-5;7) with phonological delays were examined in terms of featural distinctions in order to address universal vs. individual accounts of acquisition. Phonetic inventories of these same children were also identified for comparison purposes. Across children, four hierarchical and implicationally related types of phonemic inventory were identified. The typology uniquely captured common distinctions maintained by all children, and at the same time, allowed for individual differences in the specific phonemic composition of each system. These cross-sectional results have theoretical implications for the longitudinal course of phonemic acquisition. In particular, children appear to have a number of linguistic choices that relate to the course, the specifics, and the mechanism of change in acquisition.

[Second multicenter study of thrombocytapheresis using the Fresenius AS104 blood cell separator and ring study for quality control of cell counts. Members of the Preparative and Therapeutic Hemapheresis Section of DGTI]. / Zweite Multizentrische Studie zur Thrombozytapherese mit dem Blutzellseparator Fresenius AS 104 und Ringstudie zur Qualitätskontrolle der Zellzählung. Mitglieder der Sektion Präparative und Therapeutische Hämapherese der DGTI.

The aim of the 2nd Multicenter study was to evaluate the separation protocol software version V 4.61 of the Fresenius AS 104 cell separator, for separation efficiency, WBC contamination and yield's deviation from prediction. Plateletpheresis data from 12 hemapheresis centers, using identical apheresis protocols and cell counting methods, were registered and statistically analyzed. Additionally, the counting methods of the centers were controlled by a ring study with biweekly cell counts. To get a comparison the apheresis data, which were dependent of the center effects, were corrected by the systematical deviation found in the quality control from the ring study. The results of 935 runs are 47.3 +/- 8.1% for the separation effectivity. 7.2% median deviation from predicted yield, whereby 90% of all runs deviated less than +/- 22% from predicted yields. 50% of products had a WBC contamination below 6 x 10(6), 99% below 5 x 10(7).