Complications Associated with Alloplastic Materials in Rhinoplasty and Their Operative Management.

Whereas rhinoplasty with a reduction of the dorsum and modification of the tip is a common procedure among Caucasians, augmentation of the dorsum remains a challenge in Asians. Choice of the ideal grafting material for dorsal augmentation is a matter of preference and remains under discussion. Autologous and alloplastic materials have their advantages and disadvantages. We report our experiences of the extrusion of alloplastic materials and their management. We report of 18 patients, who had rhinoplasty in the past for dorsal augmentation with alloplastic material. Augmentation rhinoplasty was performed in Asia (n = 15) and Germany (n = 3). All cases showed recurrent signs of foreign body infection and/or partial extrusion and therefore underwent revision surgery in our centers. Once all patients had been successfully treated with antibiotics, we performed a one-stage revision rhinoplasty with explantation of the alloplastic material and subsequent reconstruction with autologous rib cartilage. The nasal dorsum was augmented with either solid rib cartilage grafts, diced cartilage in fascia, or free diced cartilage in platelet-rich fibrin. All patients received pre-, peri-, and postoperative antibiotics. The outcome was screened via clinical examination, ultrasound examination pre- and postoperatively, two-dimensional/three-dimensional (3D) imaging, and magnetic resonance imaging scans.Alloplastic augmentation of the nasal dorsum runs the risk of foreign body reaction, recurrent infections, uncontrolled scarring, and unsatisfying long-term results. We have obtained a series of aesthetically and functionally satisfying results after single-stage revision surgery with autologous cartilage and demonstrate a variety of novel postoperative screening tools including 3D imaging and high-frequency ultrasound. LEVEL OF EVIDENCE: N/A.

[Dorsal preservation septorhinoplasty]. / Die nasenrückenerhaltende "Dorsal-Preservation"-Septorhinoplastik.

BACKGROUND: Nasal dorsum deprojection is a very important tool in functional and aesthetic rhinoplasty. In classic techniques, resection of dorsal bone and cartilage renders dorsal reconstruction necessary. The concept of dorsal preservation rhinoplasty has been known for more than a century but has experienced a renaissance in recent years, with many critical technical modifications. MATERIALS AND METHODS: We present the latest technique of piezo-assisted dorsal preservation rhinoplasty with subdorsal triangular resection and subdorsal Cottle modification based on clinical experience of 205 cases. Furthermore, the advantages and disadvantages of this technique are discussed and several other current variations are presented. RESULTS AND DISCUSSION: Piezo-assisted osteotomy enables a very precise fracture line and sparing of periosteum, with bone sculpting possible even after mobilization. Subdorsal septal height reduction always precedes completion of the osteotomy and nasal bone mobilization, to ensure patient safety with regard to skull base injury. Using the presented technical modifications, the risk of step deformities in the radix is minimized. In selected patients, dorsal preservation septorhinoplasty enables the surgeon to perform very conservative and precise deprojection of the nose with excellent outcomes, although the spectrum of possible complications is shifted in comparison to classic techniques. CONCLUSION: The preliminary experience of 205 cases with a revision rate of less than 10% is promising. A final evaluation of the technique will only be possible after further studies and evaluation of long-term results.

Treatment-induced changes of lymphocyte subsets in patients with adenoid cystic carcinoma of the head and neck.

PURPOSE: Adenoid cystic carcinoma (ACC) of the head and neck is a rare and highly malignant tumor, characterized by perineural growth and early distant metastases. The composition of immune cells in the peripheral blood and the tumor microenvironment is critical to tumor growth and control. However, little is known about the frequency and function of the relevant immune cell subsets in this entity. METHODS: In ACC patients (n = 11) and matched healthy donors (n = 11), the frequency of peripheral blood T and B cells was measured by flow cytometry at different treatment stages of disease (24 samples). Cells were further characterized by their expression of CCR7, PD-1, CD39 and CD73. Tumor-infiltrating lymphocytes (TIL) were analyzed by immunohistochemistry for ten patients and for three patients by flow cytometry. RESULTS: CD4+ T cells had significantly lower frequency after radiotherapy (RT). All other cell frequencies, including Treg, were stable through course of the disease. In B cells, CD73 was reduced after RT. CCR7 expression on T and B cells in patients with relapse/metastases (R/M) differed significantly from patients with active disease. PD-1 remained stable. Treg were more present in TIL compared to peripheral blood. CONCLUSION: Composition of lymphocyte subgroups behaves similar to squamous cell carcinoma in the head and neck, except for Treg, which remained stable. Nevertheless, the CD4+/Treg ratio was lower after RT, which could stand for an immunosuppressive effect in these patients. Therefore, it could be beneficial treating ACC with combined RT and immunomodulatory drugs.

Treatment of ear keloids: algorithm for a multimodal therapy regimen.

Keloids are benign cutaneous lesions, arising from proliferating fibroblasts. Keloids of the ear may occur after trauma, surgery or helix piercings and are difficult to treat, since they tend to form recurrences. Guidelines suggest multimodal therapy; however, recurrence rates remain high and distinct algorithms for the combination of different modalities are missing. To unravel the most effective combination of therapeutic options for keloids of the ear, 38 patients with the diagnosis of an ear keloid were included in our cohort. In a prospective subgroup (B) of this cohort (n = 17), patients either underwent surgery using the "fillet technique" (a meticulous peeling of the keloid skin) and intra-lesional injections of triamcinolone 10 mg/ml every 4-6 weeks for 6 months, or they were additionally treated with a non-customized pressure device which was recommended for at least 16/24 h per day over 6 months. To further compare our results, the remaining 21 patients of our cohort, who were treated at our clinic before, were retrospectively evaluated concerning their recurrence rates. The mean follow-up was 48 months. The mean count of adjuvant steroid injections was two in all patients, four in subgroup B. The recurrence rate was 30% (13/38) in all patients (subgroup B 0/17). Aesthetic results were good to excellent in all non-recurrent cases. No patient treated with fillet technique showed recurrence (p < 0.001). However, we could not confirm a significant effect but a trend of repeated steroid injections for preventing recurrences (p = 0.099). The application of pressure using our non-customized clip also showed a clear trend towards preventing recurrences in cross-table analysis (p = 0.057). Although several studies on different treatment regimens for keloids of the ear exist, the effectiveness of a multimodal treatment regimen needs to be elucidated. Overall, the best results in preventing recurrences were achieved by combining three different treatments. However, the fillet technique was the only modality preventing recurrences of keloids in uni- and multivariate analysis. The application of pressure with a non-customized clip and repeated steroid injections also showed a positive trend but failed level of significance. Based on our data and the literature we recommend, when feasible, the combination of more than one therapeutic regimen, since relapse risk went down from single to dual and triple therapy from 40% (8/20) to 14.3% (2/14) to 0% (0/4), respectively in our cohort. The use of "fillet technique" was especially beneficial.

Synchronous bilateral tonsil carcinoma: case presentation and review of the literature.

BACKGROUND: The incidence of synchronous bilateral tonsil carcinoma seems to be underreported. For adequate oncologic treatment, it is mandatory to remove all primaries to prevent recurrence or metachronic disease. The purpose of this manuscript is to provide a comprehensive review on this topic and to emphasize the need of bilateral tonsillectomy in cases of cancer of unknown primary (CUP) as well as in the case of a unilateral tonsillar carcinoma. MATERIAL AND METHODS: A systematic review of the literature was performed for "bilateral tonsillar neoplasm", "synchronous cancer of the oropharynx" and "cancer of unknown primary in head and neck". RESULTS: We present a clinical case with bilateral tonsillar carcinoma in initially suggested cancer of unknown primary. Clinically, both tonsillar sites were unsuspicious, but in PET/CT an ipsilateral enhancement of the tonsil area was detected. The pathological work up of bilateral tonsillectomy specimens revealed bilateral squamous cell carcinoma with HPV-type 16 positivity. The review of the literature revealed 29 cases of bilateral tonsil cancer. CONCLUSION: The handling of tonsillar tissue in the frame of panendoscopy in the case of CUP is still controversial. We recommend a bilateral tonsillectomy as a routine procedure for cancer of unknown primary as well as unilateral tonsillar carcinoma. Herewith the detrimental consequences of occult metachronous contralateral tonsillar carcinoma can be prevented.

[The 8th edition of the AJCC Cancer Staging Manual : Updates in otorhinolaryngology, head and neck surgery]. / Die 8. Ausgabe der TNM­Klassifikation : Neuerungen für das Fachgebiet Hals­Nasen­Ohren­Heilkunde, Kopf- und Halschirurgie.

BACKGROUND: The TNM system is an established tool for classification of solid tumors by means of tumor size and extent, the involvement of local lymph nodes, and the presence of distant metastases. The classification was established in order to visualize prognostic implications and to allow establishment of systematic therapeutic algorithms. Since the beginning of 2017 a revised version of the classification has applied. Particularly the classification of otorhinolaryngologic tumors has been thoroughly revised in the 8th edition, partly on the basis of new prognostically relevant parameters, such as infection with oncogenic human papillomavirus (HPV) subtypes. MATERIALS AND METHODS: The 8th edition of the American Joint Committee on Cancer (AJCC) served as a basis for the review. The highlighted changes were supplemented by a literature review and the most important elements were summarized. RESULTS: Substantial changes were made for oropharyngeal carcinomas caused by HPV, for the classification of lymph node metastases under consideration of extranodal extension, and for classification of tumors of the oral cavity. Due to their frequency and special biology, skin tumors in the head and neck area are now described in a separate chapter. CONCLUSION: The new classification is a challenge for all specialties involved in tumor staging and therapy. The advantage for the patient lies in a more accurately adjustable treatment modality through more precise classification of tumors. Good collaboration and rapid implementation of the new classification is required in all disciplines involved in head neck tumor diagnostics and therapy.

[Nasal turbinate surgery]. / Nasenmuschelchirurgie.

The nose forms the first 8 cm of the upper respiratory tract and is responsible for cleansing, humidification, and temperature control of the supplied air. This is also referred to as conditioning. The nasal valve region, formed by the head of the lower nasal concha, portions of the cartilaginous septum, and the upper lateral cartilage, is responsible for diffusing and accelerating the respiratory airflow. Prerequisite are regular mucociliary clearance and sufficient air passage. Hypertrophy of the lower nasal turbinate is one of the most common causes of symptomatic nasal congestion. In unclear cases, rhinometric procedures are available. In addition to conservative therapy of allergic or vasomotor rhinitis by specific immunotherapy or topical corticoids, numerous interventional procedures are available to reduce conchal tissue. All modern methods have a high degree of protection of the respiratory mucosa in common.

Palliative treatment standards for head and neck squamous cell carcinoma : Survey of clinical routine in German-speaking countries.

BACKGROUND: The EXTREME (Erbitux in First-Line Treatment of Recurrent and Metastatic Head and Neck Squamous Cell Carcinoma) protocol is generally considered the gold standard in palliative first-line treatment. However, there is some disagreement about its effectivity, toxicity, and applicability in daily clinical routine. The purpose of this cross-sectional survey was to describe the palliative treatment offered in German-speaking countries. METHODS: From November 2013 to July 2014, 204 departments of otorhinolaryngology (ORL) in Germany, Austria, and the German-speaking parts of Switzerland were contacted and invited to take part in a web-based survey on the treatment of HNSCC. RESULTS: In all, 62 of 204 treatment centers (30.4 %) participated in the survey. Of these, 58 departments offered palliative systemic therapy to their patients; 19 of 58 (32.8 %) treated patients undergoing palliative chemotherapy in their own ORL departments, while 40 of 58 (69 %) upheld a cooperation with medical oncologists in the same hospital and 24 of 58 (41.4 %) with medical oncologic practices. Many of these treatment centers offered multiple locations for treatment. Of the 58 departments, 56 provided an institutional standard for first-line palliative treatment, 13 for second-line, and two for third-line treatment. In 42 of 58 departments the EXTREME protocol was the institutional standard of care for first-line treatment. Moreover, 12 of 58 departments mentioned an individual protocol and two of 58 the inclusion in clinical trials as their local standard. The assessment of patients who could be treated with the first-line standard ranged from 0 to 95 % with a mean of 44.5 %. CONCLUSION: Palliative systemic therapy seems to be well standardized for first-line treatment, whereas there is little standardization in second- and third-line treatments. A large variation was found regarding the estimate of the applicability of the institutional standard. Reasons for this could be the physicians' individual experience as well as the varying assessment regarding the toxicity of palliative systemic therapy.

Oncologic treatment landscape for head and neck squamous cell carcinoma : Treatment infrastructure in German-speaking countries.

BACKGROUND: The treatment of head and neck squamous cell carcinoma (HNSCC) is highly complex and requires a multimodal approach. However, guidelines for the treatment of most forms of HNSCC do not exist in German-speaking countries with the exception of oral cavity cancer. The aim of this cross-sectional study was to describe the current treatment landscape and infrastructure in German-speaking countries. METHODS: From November 2013 to July 2014, 204 departments of otorhinolaryngology (ORL) in Germany, Austria, and the German-speaking part of Switzerland were contacted and invited to take part in a web-based survey on the treatment of HNSCC. In order to cover the study in its entirety, we published three consecutive papers of which this paper is the first. RESULTS: In all, 62 treatment centers (30.4 %) participated in the survey. These centers included 21 university hospitals, 16 certified cancer centers, and 35 large centers, which diagnose at least 75 HNSCC patients annually. In 91.9 % of all cases, there were outpatient consultation hours (that were monodisciplinary in 61.4 %). A multidisciplinary tumor board was existent in 98.4 % of the cases. Of 62 ORL departments, 50 had a hospital cancer registry, 41 of 62 conducted oncological studies, and 35 of 62 assessed their patients' quality of life. CONCLUSION: The infrastructure of the treatment for HNSCC can be considered mostly well-developed and supports interdisciplinary cooperation. Potential improvements can be made regarding the standardization of tumor boards, the participation in clinical trials, and the availability of cancer registries and the data gathered therein.

[Immunotherapy of head and neck tumors: Highlights of the ASCO Meeting 2015]. / Immuntherapie von Kopf-Hals-Karzinomen: Highlights des ASCO-Kongresses 2015.

BACKGROUND: In recent years, new immunotherapeutic drugs have become available: the so-called immune checkpoint modulators. With these drugs, unprecedented treatment results have been achieved in different malignant diseases; primarily malignant melanoma, but also in various other malignomas. These achievements have revolutionized the oncologic treatment landscape. This quickly expanding research field, driven by revolutionary treatment results, has put immunotherapy in the focus of attention. OBJECTIVE: Due to rapid developments in the field of immunotherapy, this article aims at introducing, illustrating, and summarizing the field of modern immunotherapy, based on recently presented clinical data from the Annual Meeting of the American Society of Clinical Oncology (ASCO) 2015. MATERIALS AND METHODS: The most important ASCO Meeting 2015 immunotherapy trials for head and neck squamous cell carcinoma (HNSCC) were identified, summarized, and discussed with respect to the current state of research. RESULTS: The oncologic landscape of clinical trials is currently dominated by the new immune checkpoint modulating drugs. Also for HNSCC, a variety of clinical trials and substances are under way. The current primary focus of these trials is targeting and inhibiting the programmed death 1 (PD-1) axis. Cancer immunotherapy with immune checkpoint modulating drugs seems to be independent of human papilloma virus (HPV) status. Robust predictive markers for patient selection are not yet available. CONCLUSION: Current data from clinical trials with immune checkpoint modulators are promising. In the coming years, integration of these drugs into clinical routine can be expected. With regard to the public health economic burden and potential adverse events, the identification of predictive markers for patient selection is a major task for future trials.

[Value of fine needle aspiration cytology and core needle biopsy in the head and neck region]. / Stellenwert der Feinnadelaspirationszytologie und Stanzbiopsie im Kopf-Hals-Bereich.

BACKGROUND: Fine-needle aspiration cytology (FNAC) and core-needle biopsy (CNB) represent 2 minimal invasive methods for further assessment of suspect lesions of the head and neck area. However, only limited data on the direct comparison of both methods has been published. The aim of this retrospective study was to evaluate the diagnostic value of FNAC and CNB and to compare their sensitivity and specificity. MATERIAL AND METHODS: Between 2005 and 2012, CNB was performed in 86 patients and FNAC in 408 patients. 52 of 86 CNB-patients and 224 of 408 FNAC-patients underwent surgery afterwards and were included into the study (n=276). In order to compare the results of both methods the corresponding final histopathological finding from surgery was considered. RESULTS: The sensitivity of the FNAC-group was higher (85%) compared to the CNB-group (80%), the specificity (87 vs. 94%) as well as the positive predictive value (64 vs. 97%) was lower. The negative predictive value (92 vs. 71%) and also the false negative value of the FNAC (5 vs. 13%) were superior to the results of the CNB-group. Concerning the false positive value the CNB-group showed better results (2 vs. 15%). CONCLUSION: Both methods are well suited to clarify the dignity of lesions in the head and neck region. In the current case series, FNAC seemed particularly suitable for diagnosis of hematologic diseases and the exclusion of malignancy in suspicious lymph nodes. The GNP has proven to be valid in the detection of tumor recurrences in irradiated or previously operated tissue, furthermore the definitive oncological treatment can be planed, based on the histopathological results obtained by GNP.

[Molecular approaches to systemic therapy of adenoid cystic carcinoma of the head and neck area]. / Molekulare Ansatzpunkte für systemische Therapien adenoidzystischer Karzinome im Kopf-Hals-Bereich.

The adenoid cystic carcinoma (ACC) is a neurotropic salivary gland tumor with a high blood-borne metastasis tendency. The treatment of choice for localized disease consists of radical surgical resection and, depending on resection status, adjuvant radiotherapy. Due to the high recurrence rate with limited local therapeutic options and frequent occurrence of distant metastases, one is confronted inevitably with the search for an adequate systemic therapy. ACC shows little response to a variety of chemotherapeutic agents, partial or complete remissions are extremely rare. Beside classical chemotherapies, immunotherapeutics and targeted therapies with more favorable side effect profiles were tested in trials, but due to the small number of patients, a definitive statement on the effectiveness can be hardly made. This results in the need for prospective multicenter studies that allow clear recommendations for systemic therapy of the tumor. The present paper gives an overview of the sub-cellular and genetic characteristics of ACC, which represent possible targets for systemic therapies and have partly already been included in running clinical trials.

[Acromegaly-associated lesions of the nasal mucosa. Case report]. / Mit Akromegalie assoziierte Veränderungen der Nasenschleimhäute. Fallbericht.

Acromegaly is a rare disease caused by a growth-hormone-secreting pituitary adenoma. Symptoms include enlargement of the hands, feet, and jaw with growing dental interspaces, as well as hypertrophy of the tongue and nasal and sinusoidal mucosa. The two latter symptoms are mostly responsible for the accompanying obstructive sleep apnea syndrome. Besides these "cosmetic" symptoms, the disease is associated with hypertension and diabetes mellitus, as well as with an increased risk for adenomas and carcinomas of the colon. The average time span from first symptom to diagnosis is well over 6 years; a single determination of insulin-like growth factor 1 in serum can confirm the disease. The treatment of choice remains surgical resection of the adenoma in suitable patients, whereas in extensive disease with invasion of surrounding tissue, drug therapy and/or radiotherapy may be necessary.

[Management of traumatic tracheal injuries: presentation of a rare case and review of the literature]. / Behandlung traumatischer Trachealverletzungen: Präsentation eines seltenen Falles und Literaturübersicht.

BACKGROUND: Traumatic injuries of the tracheobronchial system are rare, but a big challenge for the clinician in early diagnosis and optimal management in the prevention of high fatality and morbidity. PRESENTATION OF THE CASE: We present the case of a patient with suicidal deep cervical stabbing wound and consecutive subtotal transsection of the trachea. The patient was treated by an interdisciplinary team and emergency operation was performed after admission to the hospital. Intubation was done through the stabbing wound and the knife was removed intraoperatively. After removal the knife an end-to-end reanastomosis of the trachea was performed. There were no further injuries of large vessels or the oesophagus. The long term result showed, with the exception of a unilateral palsy of the recurrent laryngeal nerve and consecutive minor dysphonia, no further morbidity. CONCLUSIONS: The management of tracheobronchial injuries consists, depending on the severity, of emergency operation, in cases of tracheal rupture, haemorrhage or oesophageal injury, or of selective operation, in cases of minor injury and clinically stable patient. In the diagnostic pathways, the clinical examination is followed by radiologic imaging, angiography, computer tomography, and tracheo-bronchio-esophagoscopy. Particularly dangerous are total tear-offs of the trachea, tracheal contusions, tracheal or oesophageal fistula and postoperative stenosis of the trachea. The prognosis of the patient is largely dependent on an early diagnosis and good interdisciplinary management.

Protocol design and current status of CLIVIT: a randomized controlled multicenter relevance trial comparing clips versus ligatures in thyroid surgery.

BACKGROUND: Annually, more than 90000 surgical procedures of the thyroid gland are performed in Germany. Strategies aimed at reducing the duration of the surgical procedure are relevant to patients and the health care system especially in the context of reducing costs. However, new techniques for quick and safe hemostasis have to be tested in clinically relevance randomized controlled trials before a general recommendation can be given. The current standard for occlusion of blood vessels in thyroid surgery is ligatures. Vascular clips may be a safe alternative but have not been investigated in a large RCT. METHODS/DESIGN: CLIVIT (Clips versus Ligatures in Thyroid Surgery) is an investigator initiated, multicenter, patient-blinded, two-group parallel relevance randomized controlled trial designed by the Study Center of the German Surgical Society. Patients scheduled for elective resection of at least two third of the gland for benign thyroid disease are eligible for participation. After surgical exploration patients are randomized intraoperatively into either the conventional ligature group, or into the clip group. The primary objective is to test for a relevant reduction in operating time (at least 15 min) when using the clip technique. Since April 2004, 121 of the totally required 420 patients were randomized in five centers. DISCUSSION: As in all trials the different forms of bias have to be considered, and as in this case, a surgical trial, the role of surgical expertise plays a key role, and will be documented and analyzed separately. This is the first randomized controlled multicenter relevance trial to compare different vessel occlusion techniques in thyroid surgery with adequate power and other detailed information about the design as well as framework. If significant, the results might be generalized and may change the current surgical practice.