Vestibular Schwannoma Surgery: Outcome and Complications in Lateral Decubitus Position versus Semi-sitting Position-A Personal Learning Curve in a Series of 544 Cases over 3 Decades.

OBJECTIVE: To retrospectively evaluate influence of intraoperative positioning (semisitting vs. lateral decubitus) and surgeon's learning curve with regard to functional outcome of patients with vestibular schwannoma. METHODS: This study included 544 patients (median age 57 years) and spanned 3 decades: 1991-1999 (n = 103), 2000-2009 (n = 210), and 2010-2019 (n = 231). Surgery was performed in the lateral decubitus position in 318 patients and the semisitting position in 163 patients. Large T3 and T4 tumors were present in 77% of patients. RESULTS: Complete tumor removal was achieved in 94.3% of patients. A significant reduction in surgery duration and blood loss was observed over 3 decades for T3 (from 325 to 261 minutes, P < 0.001) and T4 (from 440 to 330 minutes, P < 0.001), but not for T1 and T2, tumors. The semisitting position diminished surgical time in T3 and T4 tumors by 1 more hour (P < 0.001). Over 3 decades, facial nerve outcome improved significantly from 59.8% House-Brackmann grade 1-2 in the first decade to 81.7% in the last decade (P < 0.001). Furthermore, hearing was preserved in 45.3%: 23.3% of patients in the first decade and 50.5% in the last decade (P = 0.03). However, neither facial nerve outcome nor hearing preservation significantly differed in patients operated on in the lateral decubitus versus the semisitting position. The most common complication was cerebrospinal fluid leak (6.1%) followed by hemorrhage (3.5%) and pulmonary embolism (2.2%). CONCLUSIONS: Follow-up over 3 decades illustrates a learning curve with significantly improved results. While the semisitting position accelerates the procedure and is associated with reduced blood loss, it does not significantly influence functional outcome.

Mapping of language and motor function during awake neurosurgery with intraoperative optical imaging.

Intraoperative optical imaging (IOI) is a marker-free, contactless, and noninvasive imaging technique that is able to visualize metabolic changes of the brain surface following neuronal activation. Although it has been used in the past mainly for the identification of functional brain areas under general anesthesia, the authors investigated the potential of the method during awake surgery. Measurements were performed in 10 patients who underwent resection of lesions within or adjacent to cortical language or motor sites. IOI was applied in 3 different scenarios: identification of motor areas by using finger-tapping tasks, identification of language areas by using speech tasks (overt and silent speech), and a novel approach-the application of IOI as a feedback tool during direct electrical stimulation (DES) mapping of language. The functional maps, which were calculated from the IOI data (activity maps), were qualitatively compared with the functional MRI (fMRI) and the electrophysiological testing results during the surgical procedure to assess their potential benefit for surgical decision-making.The results reveal that the intraoperative identification of motor sites with IOI in good agreement with the preoperatively acquired fMRI and the intraoperative electrophysiological measurements is possible. Because IOI provides spatially highly resolved maps with minimal additional hardware effort, the application of the technique for motor site identification seems to be beneficial in awake procedures. The identification of language processing sites with IOI was also possible, but in the majority of cases significant differences between fMRI, IOI, and DES were visible, and therefore according to the authors' findings the IOI results are too unspecific to be useful for intraoperative decision-making with respect to exact language localization. For this purpose, DES mapping will remain the method of choice.Nevertheless, the IOI technique can provide additional value during the language mapping procedure with DES. Using a simple difference imaging approach, the authors were able to visualize and calculate the spatial extent of activation for each stimulation. This might enable surgeons in the future to optimize the mapping process. Additionally, differences between tumor and nontumor stimulation sites were observed with respect to the spatial extent of the changes in cortical optical properties. These findings provide further evidence that the method allows the assessment of the functional state of neurovascular coupling and is therefore suited for the delineation of pathologically altered tissue.

Hoarseness ­ causes and treatments. / Heiserkeit Ursachen und Therapie.

Due to a hoarseness or dysphonia about 1 % of patients consult a doctor. The causes of hoarseness are very diverse and can range from a harmless laryngitis to vocal cord tumors. In addition to acute and chronic laryngitis (42 % and 10 %), functional dysphonia (30 %), benign (15 %) and malignant tumors (3 %), vocal cord paresis (5 %), the physiological aging voice (2 %) and psychogenic factors (2 %) can cause hoarseness. The manifestation of internal diseases is very rare. Treatment options depending on the cause are drugs, voice therapy or surgery. The present article gives an overview of possible causes of hoarseness, diagnosis and treatment options. Hoarseness lasting more than three weeks should always be taken seriously and be examined laryngoscopically.

[Differential diagnostic and therapeutic aspects of nasal obstruction]. / Differenzialdiagnostische und therapeutische Aspekte.

A nasal obstruction can have various causes. This publication describes various diseases of the nose and paranasal sinuses which cause nasal obstruction or which are associated with the symptom of nasal obstruction. The diagnosis and treatment of the diseases is discussed. Anatomical, physiological aspects and the general diagnosis of diseases of the nose and sinuses are also considered.

Laterality of sudden sensorineural hearing loss.

It is known that sudden sensorineural hearing loss and other otoneurologic diseases, such as tinnitus or Ménière disease, occur more frequently in the left ear than in the right. We studied lateralization of sudden deafness in 489 patients treated at Radebeul Hospital from January 2004 to December 2009. The male-to-female ratio was 1:1.24; we found a predominance of the left side only in female patients. The cause for this predominance is unclear. The slight asymmetry might indicate a greater vulnerability of the left inner ear in women, suggesting hormonal factors in the genesis of sudden deafness.

Assessment of visual function during brain surgery near the visual cortex by intraoperative optical imaging.

Several functional brain imaging and mapping techniques have been used for the intraoperative identification and preservation of the sensory, motor, and speech areas of the brain. However, intraoperative monitoring and mapping of the visual function is less frequently performed in the clinical routine. To our knowledge, here we demonstrate for the first time that the individual visual cortex can be mapped to the brain surface using a contact-free optical camera system during brain surgery. Intraoperative optical imaging (IOI) was performed by visual stimulation of both eyes using stobe-light flashes. Images were acquired by a camera mounted to a standard surgical microscope. Activity maps could reproducibly be computed by detecting the blood volume-dependent signal changes of the exposed cortex. To the preliminary experience, the new technique seems to be suitable for mapping the visual function in any neurosurgical intervention that requires exposure of the visual cortex. However, the clinical relevance and reliability of the technique need to be confirmed in further studies.

[Pharmacotherapy of acute and chronic tinnitus]. / Die medikamentöse Therapie des akuten und chronischen Tinnitus.

The aetiology of acute tinnitus is mostly idiopathic like sudden sensorineural hearing loss or caused by noise and rarely infectious or vascular. Therefore there is currently no causal and effective drug therapy available. Although there is a low level of evidence, treatment with glucocorticoids and initially plasma expanding infusions (HES) is recommended for acute tinnitus if there is no spontaneous remission. Intratympanic glucocorticoid therapy can be used as an alternative if there is severe hearing loss together with tinnitus. In chronic tinnitus there is really no indication for pharmacotherapy. Sometimes

[Conservative therapy of chronic sinusitis]. / Therapie der chronischen Rhinosinusitis.

The chronic rhinosinusitis is defined as chronic inflammation of the nose and nasal sinuses, with or without nasal polyps. Patients suffering from chronic rhinosinusitis report about nasal obstruction and secretion, olfactory impairment, head and facial pain. These symptoms cause also considerable impact on quality of life. Therefore, an adequate rhinological diagnostics as well as therapies are essential. This paper reviews the pharmacologic and non-pharmacologic therapy of chronic rhinosinusitis. First choice of therapy should be topical glucocorticoids. The application of glucocorticoids causes anti-inflammatory and certain curative effects. Hypertonic salt solutions improve nasal symptoms. Long-term therapy with oral macrolides might improve median to severe symptoms of chronic rhinosinusitis without nasal polyps. An additional therapy with antihistamines is possible in patients with an allergy. Adaptive desensitization in patients suffering from analgesic-intolerance associating among other with nasal polyps is currently the single causal therapy. Therefore, frequency of endonasal revision surgery is reduced after desensitization.

Epistaxis: some aspects of laterality in 326 patients.

Lateralization of primary epistaxis was prospectively studied in 326 patients at Radebeul Elblandklinikum. The male-female-ratio was 1.3:1. A slight dominance of the right side (45% right vs. 39% left) was found in all patients. Further analyzed were the relationship to the localization of bleeding (anterior or posterior), the age and possible causes or risk factors. Nose bleeding from the posterior nasal portion appears to be statistically significantly higher than on both sides of anterior epistaxis. No statistically significant age dependence of laterality of epistaxis was observed in the age groups which we selected. However, nosebleed appears more frequently in women under the age of 50 years in both nostrils. With identified risk factors, idiopathic epistaxis occurs more frequently on the right side than does nosebleed. Mechanical trauma (intranasal sprays or nose picking) is a possible factor explaining the dominance of epistaxis on the right side, especially in idiopathic cases.

Vestibular neuritis: is there any evidence of an asymmetric distribution?

Statistics in the literature showed that neuro-otological diseases (i.e. sudden hearing loss or tinnitus) occur predominantly in the left ear. In a seven-study meta-analysis of patients suffering from vestibular neuritis, Reiß found no clear dominance of one side (50.8% on the right side, 48.4% on the left side and 0.8% on both sides). The purpose of this study is to investigate the laterality of vestibular neuritis in a distinct population of patients. Lateralization of vestibular neuritis was studied in 160 patients treated at Elblandklinikum Radebeul from January 2004 to December 2009. There was a statistically non-significant dominance of the right side in the total sample, specifically in female patients (57% right vs. 40% left), but not in male patients. The study confirms the results of the meta-analysis: that there is no relevant side dominance in patients suffering from vestibular neuritis. In addition to the caloric test, the head impulse test was performed in 157 patients. In 92% of these patients, the disturbance of vestibular function could be confirmed with the head impulse test. This test is altogether a clinically useful instrument especially for follow-up, but also for diagnosis.

Height of right and left ethmoid roofs: aspects of laterality in 644 patients.

Objective. The goal of the study was to determine the asymmetric distribution of the height of the ethmoid roof (fovea ethmoidalis). Method. We retrospectively reviewed 644 coronal sinus computer tomography (CT) scans. The height of the ethmoid roof was examined for possible lateral differences between the right and left sides. Results. In 221 CT scans (31%), there was an asymmetry between the height of the fovea ethmoidalis on the right and left side. Of these 221, 160 (72.4%) were lower on the right side, whereas 61 (27.6%) were lower on the left. The height of the ethmoid roof of the remaining 433 patients (66%) was symmetric. There were statistically significantly more asymmetric cases in men than in women (38% versus 29%). Conclusions. The present paper underlines the asymmetry, variability of the ethmoid roof, and the possible practical implications arising from that fact. The asymmetry of the roof of one side presents an additional point of consideration for careful preoperative and perioperative review of paranasal sinus CT scans in patients undergoing endonasal sinus surgery.

[Epistaxis: diagnosis and therapy]. / Epistaxis: Ursachen, Diagnostik und Therapie.

Epistaxis or nosebleed is one of the most frequent emergencies in otorhinolaryngology. It is clearly an important condition--not only to the ear-nose-throat (ENT)-specialist but also to any general practitioner. This review looks at the aetiology, associated clinical considerations and evolution of its management. Intractable epistaxis requires a broad armamentarium of different diagnostic and therapeutic options.

[Suppurative chronic otitis media: etiology, diagnosis and therapy]. / Die chronische eitrige Otitis: Ursachen, Diagnostik und Therapie.

The chronic otitis media is defined as a permanent perforation of the drum membrane, which does not close by itself, and an inflammatory reaction in the mucosa (mucositis) of the middle ear. Two main forms of the chronic otitis media are distinct: the suppurative otitis media and the cholesteatoma. The suppurative otitis media is often accompanied by secretion into the external ear canal (otorrhoe), but "dry ears" are also common. Other frequent, but not obligatory symptoms are hearing impairment, tinnitus, and aural pain or pressure. Although genetically determined microbial and immunological factors, as well as Eustachian tube characteristics, are supposed to be involved in the pathogenesis of chronic suppurative otitis media, many aspects of the pathogenesis still need to be clarified. Ear microscopy will show the perforation in the drum membrane. Further diagnostic tools are audiometry, vestibular testing, radiological examination (high-resolution computed tomography) and microbiological investigation. The curative treatment for chronic suppurative otitis media is surgery (tympanoplasty, i.e. closure of the perforation in the drum membrane and also--if necessary--the reconstruction of the ossicular chain), not conservative antimicrobial therapy.

[Presbyacusis: pathogenesis and treatment]. / Schwerhörigkeit im Alter. Ursachen und Behandlung.

Although many adults retain good hearing as they age, hearing loss associated with ageing is common among elderly persons. There are a number of pathophysiological processes underlying age-related changes to functional components. Presbyacusis is especially caused by cochlear degeneration, most pronounced in the basal cochlear coil. Factors include physiological ageing processes as well as endogenous or exogenous causes. The common form of hardness of hearing seen in old age is not due to physiological age-related changes, but rather to a complex sensorineural pattern of injury. In the industrial countries, two main exogenous causes are exposure to loud noise and obesity. Pathomechanisms contributing to presbyacusis are hypoxia/ischemia, reactive species formation and oxidative stress, apoptotic and necrotic death of hair cells and spiral ganglion cells as well as inherited and acquired mutations in the mitochondrial DNA. Important for the successful treatment of presbyacusis is a timely fitting of hearing aids on both ears to improve communication, provide the auditory system with acoustic information, and potential prevention of social isolation. At present, several therapeutic interventions are under discussion. The application of antioxidants or caloric restriction is considered to prevent or reduce oxidative stress-induced damage. A further approach may be the overexpression or modulation of the superoxide dismutase 2 (SOD2) within the cochlea. Hair cell regeneration could also be a possible treatment of presbyacusis in the future.

[Analgesic intolerance: pathogenesis, diagnosis and treatment]. / Analgetikaintoleranz. Ursachen, Diagnostik und Therapie.

Analgesic intolerance brings on cutaneous, respiratory and/or gastrointestinal reactions. This review provides an overview of sensitivity to nonsteroidal anti-inflammatory-drugs (NSAR) and its management. The full clinical picture of analgetic intolerance--the association of bronchial asthma (with severe acute attacks), sensitivity to NSAR and nasal polyps--is commonly summarized as the "Samter triad". The symptoms include chronic rhinosinusitis with nasal polyps, asthma bronchiale, gastrointestinal ulcers, angioedema, and urticaria. The prevalence of analgetic intolerance in the general population ranges from 0.6 to 2.5%. Clinical reactions after ingestion of NSAR are often obvious in the further progress of disease. In order to initiate early therapy the diagnosis of analgesic intolerance should occur before the complete picture of analgesic intolerance is obvious. Carefully controlled challenge tests with acetyl salicylic acid or other NSAR are performed as the diagnostic but not potential undamaged tool of choice. Adaptive desensitization (Aspirin desensitization therapy) is currently the single causal therapy. Severe asthma and reactions after ingestion of NSAR are avoided. Frequency of endonasal revision surgery is reduced after desensitization.