[Primary carcinoma of the ear canal. Clinical aspects, intratemporal growth behavior and surgical strategy]. / Das primäre Gehörgangskarzinom. Klinik, intratemporales Wachstumsverhalten und operative Strategie.

BACKGROUND AND OBJECTIVE: The symptoms and microscopic findings in carcinoma of the external auditory meatus are often unspecific and misinterpreted as recurrent otitis externa. A definite diagnosis is therefore often delayed, frequently resulting in advanced tumor stages with unfavorable prognosis at the time of diagnosis. PATIENTS/METHODS: In a retrospective analysis of 11 of our own patients and four cases from the Wittmack collection, the clinical data and course of this disease were examined with particular focus on the intratemporal bone growth pattern and possible surgical strategies. RESULTS: Histopathologically, all cases consisted of squamous cell carcinoma of variable differentiation, with predomination of higher tumor stages (T2-T4: 93.3%) and little initial lymph node metastases (N+: 14.3%; M+: 0%). Osseous destruction was present (almost obligatory) in 93.3% (determined histopathologically and radiologically with CT). Follow-up (to a maximum of 6 years) after surgical resection and postoperative irradiation shows local recurrence at an average of 10 months in 40% of the cases, with a metastasis rate of 44.4%. Mean overall survival is 29.7 months, and 45.5% of the patients experience an average tumor-free period of 46.4 months. The most important prognostic factor in this context is the initial tumor stage. CONCLUSION: In regard to prognosis of external auditory meatus carcinoma, early diagnosis is of vital importance. Especially older patients (50-80 years) who previously have had no history of ear disease should undergo early computer tomographical examination and biopsy in cases of recurrent external otitis.

[Indications and surgical treatment of large middle ear abnormality]. / Indikation und chirurgische Behandlung der grossen Mittelohrmissbildung.

Children with atresia of the external auditory canal should undergo hearing assessment and fitting of a bone conduction hearing aid as early as possible to allow speech to develop normally. Surgery is done between 5 and 6 years of age, guided by high-resolution computed tomography, which provides a more precise diagnosis based on the abnormalities seen. The temporomandibular joint lies more posteriorly than normal due to aplasia or hypoplasia of the tympanic bone, so that the middle ear must be approached through the mastoid, resulting in a less favourable coupling to the middle ear structures. In unfavourable cases bone anchored hearing aids, creation of a meatus for fitting a hearing aid or a bone conduction hearing aid must be considered.

[Differential diagnosis of tumor-induced facial paralysis. Chordoma of the craniocervical transition]. / Zur Differentialdiagnose tumorinduzierter Fazialisparesen. Das Chordom des kraniozervikalen Ubergangs.

A chordoma rarely arises in the head and neck: it is considered as malignant because of its clinical behaviour and histological appearances. Usually chordomas paralyze the third to the sixth cranial nerves. We report a paralysis of the facial nerve, an event not so far reported as an early symptom of chordoma of the head and neck.

[Neurofibromatosis in the ENT field]. / Die Neurofibromatose im HNO-Bereich.

As the neurofibromatosis does not only show on the neuroderm, but also on the mesoderm, all tissues and organs of the human body can be affected. A central and peripheral form is known. Classical symptoms and major diagnostic criteria will be described. The therapy will be illustrated on four cases.

[Tumors of the parapharyngeal space. Topographical anatomy, diagnosis, therapy, literature review]. / Tumoren des Parapharyngealraumes. Topographische Anatomie, Diagnostik, Therapie, Literaturübersicht.

The borders of the parapharyngeal space are formed of fasciae of muscular tissue. Its lateral border is formed by the bone of the mandible, while its cranial border is formed by the petrous bone. The initial symptoms of parapharyngeal tumors are diagnostically volatile because of the soft tissue contents of the parapharyngeal borders. For diagnostic reasons, it has to be decided whether to extirpate tumor immediately in order to obtain a specimen for histological evaluation or whether extensive presurgical examinations are necessary. Aside from multiple serological investigations for infectious diseases, these include all kinds of noninvasive morphological procedures such as CT scan, MR scan, transcutaneous and endoscopic B-mode sonography. In addition, invasive procedures such as arterial angiographies and the taking of specimens may be necessary in some cases.

[Complications of endonasal surgery of the paranasal sinuses. Special anatomy, pathomechanisms, surgical management]. / Komplikationen der endonasalen Chirurgie der Nasennebenhöhlen. Spezielle Anatomie, Pathomechanismen, operative Versorgung.

Statistics show that there is no significant increase in complications in endonasal sinus surgery of the ethmoid or sphenoid as compared to paranasal or transantral procedures. Exact anatomical knowledge of the nasal cavity, the paranasal sinuses and related structures is essential for assessment and management in iatrogenic complications, which are divided in three groups, according to characteristic topographic implications: orbito-ocular, vascular, encephalomeningeal. Orbito-ocular complications are managed by decompression of the orbit using the paranasal approach. Direct lesions of the optic nerve in ethmoid- or sphenoid-sinus surgery are extremely rare and are due to an abnormal nervous course. Vascular complications in the branches of the external carotid artery require local procedures (e.g. transantral ligature of the sphenopalatine artery). In some cases an intra-arterial embolization using supra-selective angiography is more effective. Massive bleeding from lesions of the internal carotid artery is stopped by placement of a balloon catheter combined with a transfemoral intra-arterial digital subtraction technique. Iatrogenic dura defects in the frontal skull base can be managed easily once the lesion has been exactly and clearly localized. Adequate control of the frontobase including the orbit, optic nerve and related vascular and nervous structures is achieved by the extracranial subfrontal paranasal (Killian incision) approach, if endoscopic or endonasal microscopic repair is ineffective.

[Pulse oximetry in surgery of the bronchial system]. / Pulsoximetrie bei Eingriffen im Bronchialsystem.

Oxygen saturation was determined by pulse oximetry in 35 children and adults during general anaesthesia using jet- or manually assisted ventilation for minor elective laryngeal and tracheo-bronchial surgery. The method is non-invasive and provides continuous information about the arterial oxygen saturation (saO2) and heart rate. Compromised arterial oxygenation during anaesthesia and the effects and brief ventilatory arrest are accurately detectable. Data such as pO2, pCO2 or pH cannot be assessed by pulse oximetry; carbon monoxide and methemoglobinaemia may lead to less accurate results. Pulse oximetry provides on-line information about sudden hypoxic events and allows early therapeutic intervention because arterial desaturation precedes the clinical signs and symptoms of hypoxia.

[Personal experiences with audiometric detection of perilymph fistulas]. / Unsere Erfahrungen mit dem audiometrischen Nachweis von Perilymphfisteln.

Rupture of the round window membrane is thought to be important in the pathogenesis of sudden hearing loss. In 1982 Fraser and Flood proposed an audiometric test to improve the indication for tympanoscopy which, in their experience, verified the diagnosis of perilymph fistulae in a high percentage of cases. Between 1 January 1986 and 30 June 1988 the above test was carried out on 74 patients at the ENT Department of the University of Hamburg. In 41 cases a tympanoscopy was performed. In 13 cases with a positive test result not a single perilymphatic fistula could be found intra-operatively, while in 3 cases of rupture the test was negative. In our experience this test is not helpful for the pre-operative assessment of tympanotomy in sudden hearing loss.

Pneumatization and mesenchyme in the human middle ear.

The normal pneumatization in human middle ears from Wittmaack's temporal bone collection (ENT Clinic, University of Hamburg Medical School) is investigated by means of light microscopy and compared with electron-microscopic findings in the rat. The fetal middle ear in man and rats is completely filled with mesenchyme. The compartmentalization of the middle ear by the associated mucosal folds of the ossicular chain and the middle ear pneumatization are results of the resorption of the mesenchyme present. Ultrastructural findings in the rat's middle ear reinforce light-microscopic studies and provide evidence of the fibrillogenesis which characterizes the transformation of the mesenchyme into the tunica propria of the middle ear mucosa. The microtopography of mesenchymal remnants in middle ears of neonates and in children during the first year of life, and their relevance as to the pathogenesis of the primary acquired keratoma (cholesteatoma) are discussed.

[The lateral forehead flap in the management of defects of the exterior aspect of the nose]. / Der laterale Stirnlappen zur Versorgung von Defekten der äusseren Nase.

The closure of skin defects after tumour exstirpation in the external nose can be carried out by means of median forehead flaps. The classical technique requires a vertical forehead incision corresponding to the longitudial axis of the vasculo-muscular pedicle of the donor site. This vertical scar will subsequently not always yield an optimum aesthetic result. We prefer a modification of this method: The pedicle of the lateral forehead flap is developed stepwise through horizontal incisions which are placed in skin creases of the forehead. The defect of the donor site is closed with a rotation flap. The advantage of this procedure is an optimum aesthetic long-term result.

[Topography of the round window and its significance for the surgical therapy of perilymph fistulas]. / Die Topographie des runden Fensters und ihre Bedeutung für die chirurgische Therapie der Perilymphfisteln.

The clinical findings concerning the diagnosis of a rupture of the round window membrane vary widely. Therefore, microtopography of the round window was studied using 45 serially sectioned human temporal bones of the Wittmaack Collection, ENT Clinic, University of Hamburg. Our morphometrical data show a great variety in respect of the dimension of the round window membrane and the angle between the window membrane and the tympanic membrane. The extension and the microtopography of the promontory are as variable as the mucosal folds in the round window niche. It can be concluded that a direct view of the round window membrane is possible only in rare cases. Surgical manipulations to improve the view of the round window should be avoided because of the danger of an iatrogenic lesion of the inner ear.

[Therapy of advanced hypopharyngeal carcinoma]. / Die Therapie des fortgeschrittenen Hypopharynxkarzinoms.

Patients with hypopharynx carcinoma underwent planned irradiation and surgical treatment (pharyngo-laryngectomy with uni- or bilateral neck dissection) with postoperative planned irradiation. One group of these patients was treated with intraarterial chemotherapy with Methotrexat prior to any other therapy. The group with intraarterial therapy followed by irradiation seems to give the best results.

[Reaction of the tympanic tensor muscle--elicited by nasally applied trigeminal stimulants]. / Reaktion des M. tensor tympani--ausgelöst durch nasal applizierte Trigeminusreizstoffe.

Computerised evaluation of tensor muscle reaction was carried out by using a biosignal analysing unit triggered by nasal inhalation. The trigeminus nerve was stimulated by application of 3-molar acetylacetic acid into the nasal respiratory air, inducing a contraction of the tympanic muscle, followed by a change in impedance. This change in impedance of the tympanic membrane ossicle system was recorded and printed out on a display. In this manner evidence was obtained of a tensor muscle reaction induced by the third branch of the trigeminal nerve as efference, and demonstrated for the first time. This reflex arc had long been considered as being of negligible clinical importance before its stimulation and measurement had become possible. It is a generally accepted theory that the reflex arc of the m. tensor tympani is linked to the formatio reticularis which assesses the sensory afferences. For this reason, the reflex arc habituates rapidly, and continuous stimulation is no longer possible.

[Scar neuroma following tumor operations of the head and neck. Immunohistologic studies, differential diagnosis, therapy]. / Narbenneurome nach Tumoroperationen im Kopf-Halsbereich. Immunhistologische Untersuchungen, Differentialdiagnose, Therapie.

Amputation neuromas occasionally follow division of the cervical plexus during classical neck dissection. They present as painful, subcutaneous, and fixed tumours. They must be removed to exclude recurrence of the primary disease. The differential diagnosis includes neurilemmoma, solitary neurofibroma, neurofibromatosis, neuro-muscular hamartoma, and benign myxoid tumours. Histological diagnosis is particularly easy especially if immunohistochemistry with markers against neural tissues is used. However, to prevent recurrence, the central nerve stump should be exposed, ligated after removal of the neuroma and then transposed to scar free subcutaneous tissue.

The development of the ossicular ligaments in the human middle ear.

We examined serially sectioned human temporal bones of fetuses and newborns from Wittmaack's temporal bone collection at the University of Hamburg. At the end of the 3rd month of fetal development, a concentration of mesenchyme arises in the area which later contains the ossicular ligaments. The anlage of these ligaments can be clearly identified in the 4th month of development. The longitudinal axis of the cells in this anlage first runs parallel with the surface of the ossicles. In the further stages of development with increasing fibrillogenesis the cells straighten out according to the physiological stresses. Differentiation of the ligaments is terminated at the end of the 9th month.

Fetal development of the tympanic part of the facial canal.

We studied human middle ears from Wittmaack's temporal bone collection in the ENT Department of the University of Hamburg. In the 12-week-old fetus, cells from the embryonic middle ear mesenchyme form a tiny semi-circle around the tympanic part of the developing facial nerve. During the following weeks, the production of fibrillar material increases until the facial nerve is surrounded by a dense fibrous semi-canal. Intramembranous ossification starts from ossification centers in the anlage of the membranous facial canal. Bone appears first in the form of spicules surrounded by osteoblasts. At this time, so-called aplastic areas (aplastische Zonen) can be identified between these spicules. Their importance in the latter occurrence of dehiscenses in the mature facial canal is discussed.

[Endoscopic B-mode sonography of the neck. Preliminary findings]. / Endoskopische B-mode-Sonografie des Halses. Vorläufige Befunde.

This is the first report about cross-sectional echography of the parapharyngeal and paraoesophageal neck tissue by using an endoscopically positioned ultrasound linear-array transducer system. Technique and initial clinical results are demonstrated. Transcutaneous and endoscopic B-mode-sonographic findings are compared. Small tumours of parapharyngeal and paraoesophageal space can be detected by endosonography. Scars, oedema, and tumour can be differentiated. In addition to transcutaneous B-mode-echography, endoscopic echography can optimise the follow-up of head and neck tumours.

Pleomorphic adenomas, adenoid cystic carcinomas and adenolymphomas of salivary glands analysed by a monoclonal antibody against myoepithelial/basal cells. An immunohistochemical study.

Myoepithelial and basal cells were identified by a monoclonal antibody raised against keratin. This antibody (CK B1) which detects myoepithelial cells in normal salivary glands, labels spindle shaped and polygonal cells in pleomorphic adenomas. Most cells in adenoid cystic carcinomas and some basal cells in adenolymphomas were also positive for this antibody. The oncocytic epithelium of adenolymphoma was negative. An inverse reaction was seen with an antibody against cytokeratin 18. The antibody CK B1 seems to be of interest for the detection of myoepithelial/basal cells in salivary glands and salivary gland tumours.