[Dynamic imaging in diagnosis of dysphagia and globus sensation]. / Dynamische Bildgebung bei der Diagnostik von Dysphagie und Globus.

BACKGROUND: Videofluoroscopy has gained high significance for the evaluation of deglutition disorders. Imaging alone cannot clarify whether the subjective symptom is represented morphologically or whether it is the substrate of a functional disorder. METHOD: The videofluoroscopies of 101 patients with dysphagia (n = 55) and globus pharyngitis (n = 46) were evaluated. Morphologic abnormalities were registered as well as sequential movement patterns. These data were compared with clinical and endoscopic findings. RESULTS: In 87% of the dysphagia and 74% of the globus patients videofluoroscopy revealed pathologic findings. Functional disorders were seen significantly more often than morphologic abnormalities. Highest incidence was found for cricopharyngeal dyskinesia (42%). Hypopharyngeal pouches and degeneration signs of the cervical spine with bolus impression less than 40% are common but functionally not important. Additional esophago-gastroduodenoscopy was pathological in 83% in the dysphagia group and 96% in the globus group. CONCLUSION: Videofluoroscopy is indispensable for the differential diagnosis of dysphagia and globus sensation, especially for the detection of functional disorders in the pharyngoesophageal segment thus documenting the dynamic aspect of deglutition. Videofluoroscopy should be completed by a gastroenterologic examination in order to improve diagnosis.

[Influence of comorbidity on the prognosis of squamous cell carcinoma in the head and neck]. / Einfluss von Begleiterkrankungen auf die Prognose von Plattenepithelkarzinomen im Kopf-Hals-Bereich.

BACKGROUND: The influence of comorbidity on the healing process and the prognosis of patients with carcinoma of the head and neck region undergoing surgical treatment is not clear. PATIENTS AND METHODS: In a retrospective study we examined the influence of coexistent diseases in 203 patients, hospitalized for curative surgical treatment. Findings on admission, supplemented by medical, anaesthesiological and neurological assessments, helped to form two subgroups: one of patients with minimal comorbidity (n = 135) and one with high comorbidity (n = 68). Subsequently the duration of hospitalization, incidence of complications, disease-free interval and survival was statistically compared. RESULTS: The duration of hospitalization, the incidence and degree of complications, the disease-free interval and the overall survival differed significantly, showing better results in the group with low comorbidity. CONCLUSION: Coexistent, mainly medical, diseases had a significant influence on the results of surgical treatment and prognosis of head and neck cancer.

[Deglutition disorders]. / Schluckstörungen.

Dysphagia is related to the impairment of food passage from the mouth to the stomach. Globus pharyngis implies the frequent and often painful sensation of a lump in the throat that usually does not interfere with swallowing and may even be relieved by food intake. The diagnosis is based upon a careful history, clinical examination, endoscopy, dynamic imaging (videofluoroscopy, cinematography, videosonography) and electrophysiologic procedures (including pharyngoesophageal manometry, electromyography and pH determinations). Structural lesions of the cervical spine such as diffuse idiopathic skeletal hyperostosis are rare causes of dysphagia. Dysphagia following anterior cervical fusion as well as globus and dysphonia due to dysfunction of the vertebral joints are more likely. Symptoms with swallowing fluids indicate a neurogenic origin. Dyscoordinated swallowing, nasal reflux, dysphonia or general weakness may also occur. Chronic aspiration with respiratory compromize is the main consequence in a variety of neurological disorders as well as in cases of postsurgical dysphagia. Relaxation of the upper esophageal sphincter indicates coordinated muscle movement between the pharynx and esophagus. Dysfunction of the pharyngoesophageal segment may lead to cricopharyngeal achalasia. A dyskinetic sphincter commonly represents an extrapharyngeal cause: i.e., disease associated with gastroesophageal reflux. Disorders of the esophageal phase of deglutition can produce retrosternal pain, heartburn, regurgitation and vomiting, as well as laryngeal and respiratory signs. Esophageal motility disorders include lower achalasia, tumors, peptic strictures, inflammatory diseases, drug-induced ulcers, rings and webs. Motility disorders present with aperistaltic, spontaneous contractions, diffuse esophagospasm, or a hypermotile esophagus. Gastroesophageal reflux with esophagitis must always be excluded, especially in patients with a globus sensation. The multiple features of the appearance of the symptoms of dysphagia and globus makes multidisciplinary approach necessary in order to establish a diagnosis and begin effective treatment.

[Globus pharyngis and gastroesophageal equivalents]. / Globus pharyngis und gastroösophageale Aquivalenzen.

BACKGROUND: Globus sensation is a phenomenon of largely unknown etiology. Dyskinesia of the upper esophageal sphincter is quite often evident without pathological ENT findings elsewhere. PATIENTS AND METHODS: One hundred ten patients were examined in a interdisciplinary approach. The investigation included videofluoroscopy, esophagogastroduodenoscopy with biopsy, pharyngoesophageal computer manometry, and esophageal pH monitoring. One hundred five cases were evaluated. RESULTS: In 13 cases (12.4%) there was no evidence for any organic or functional disorder. In 92 cases (87.6%) abnormal findings were seen with two constellations being predominant. These are primarily inflammatory lesions in the stomach or the duodenum in 69.5% of all patients (73/105) associated with helicobacter pylori colonization in 58% (42/73) as well as ulcera and/or erosions in 8.2% (6/73). Concurrent disorders of the lower esophageal sphincter play the second role. Sixty-one point nine percent of all patients (65/105) had an hiatal hernia, with gastroesophageal reflux in 36.9% (24/65). In 21.5% (14/65) a reflux esophagitis was evident. A cardiac sphincter insufficiency was found in 6.7% (7/105). CONCLUSIONS: Based on these findings a gastroenterologic diagnosis is recommended in all patients with globus sensation as the symptom may be associated with corresponding disorders.

[Case report: swallowed hearing aid]. / Fallbericht: Verschlucktes Hörgerät.

An 86-year-old man presented ambulatory with acute dysphagia. Radiologic examination and endoscopy revealed a swallowed postauricular hearing aid. The earmold of the hearing aid became visible in the hypopharynx after mucus and saliva were removed. It could be extracted without effort once the connecting tube was disconnected from the coupling device lodged in the upper esophageal sphincter. The hearing aid itself was impacted in the proximal esophagus and was extracted without any problems. The postoperative phase was uneventful with normal swallowing and discharge. Technical inspection revealed that the hearing aid no longer worked. Diffusion of toxic substances (zinc, mercury) from the impacted batteries is not to be expected.

[Computerized manometry concept for site-specific reconstruction of the pharynx and pharyngo-esophageal transition]. / Computermanometrisches Konzept zur etagenbezogenen Rekonstruktion von Pharynx und pharyngoösophagealem Ubergang.

Fifty-three patients who underwent laryngopharyngeal cancer surgery were examined with a sequential computer manometry system using 4-channel pressure probes. Swallowing coordination is largely independent of the oropharyngeal pressure thrust nor of the pharyngeal transit time and depends mainly on initiation of swallowing. The points of interest are the pharyngeal entrance and outlet. The topographic correlates are the base of the tongue and the upper esophageal sphincter. Resections of the base of the tongue decrease the volume available for pressure generation reducing the driving force of the tongue. Thus, reconstruction at the base of the tongue must provide more bulky-tissue coverage (i.e. myocutaneous flaps) in order to avoid cranial release of pressure and to bring about initiation of swallowing. Resections of the pharyngoesophageal segment cause circular defects that affect the sphincter, reducing hypopharyngeal suction. Thus, the resistance to bolus flow is generally increased, but can be compensated for by an increased driving force of the tongue. Additional pharyngeal and/or lingual resections increase the lumen discontinuity between the wide pharynx and the narrow esophagus, exceeding any compensatory possibilities. Plastic reconstructions therefore have to compensate for different lumina distally. In the region of the upper esophageal sphincter, softer and smoother tissue coverage is warranted in order to facilitate bolus transfer or passive bolus flow if necessary. For that purpose we modified the myofascial pectoralis-major-flap. It covers defects where a soft lining is required. The resistance to bolus flow is reduced, alleviating the need to increase the driving force of the tongue which would otherwise increase to compensate for the defect.

Dysphagia after pharyngolaryngeal cancer surgery. Part I: Pathophysiology of postsurgical deglutition.

Eighty-one patients were examined after laryngopharyngeal cancer surgery with a sequential computer manometry system using 4-channel-pressure probes. The general swallowing coordination is neither a matter of the oropharyngeal pressure thrust nor of the pharyngeal transit time, but mainly depends on swallowing initiation. The points of interest are both the pharyngeal inlet and outlet. The topographic correlates are the base of the tongue and the upper esophageal sphincter (UES). Resections of the base of the tongue lead to a decrease of volume available for pressure generation, thus reducing the tongue driving force. The swallowing reflex is uncoordinated resulting in dyskinesia of the UES. Compensation may be achieved with a stronger oropharyngeal thrust and/or repeated swallows. Distal resections alter the pharyngoesophageal segment so that a functional obstruction results, combined with lower pressure amplitudes in the hypopharynx, reducing the pressure gradient necessary for bolus flow. This increasing resistance can be overcome by higher propulsive forces in the base of the tongue region. In case of additional lingual defects, deglutition is subject to decompensation, highlighting the major role of the tongue as a pressure generator for bolus passage.

Dysphagia after pharyngolaryngeal cancer surgery. Part II: Implications for reconstructive procedures.

In the base of the tongue region, reconstructive procedures have to provide more bulky-tissue coverage (i.e., myocutaneous flaps) in order to avoid cranial release of pressure and to bring about swallowing initiation. Resections of the pharyngoesophageal (PE) segment cause circular defects, always affecting the sphincter and necessarily relaxation, thus reducing the hypopharyngeal suction pump. The resistance to bolus flow, therefore, is generally increased but can be compensated by a stronger tongue driving force. In addition to the functional obstruction, special attention is called to the growing lumen discontinuity between the wide pharynx and the narrow esophagus. Plastic reconstructions, therefore, have to compensate for different lumina distally. Following ablative surgery in the upper esophageal sphincter region, a softer and smoother tissue coverage is warranted in order to facilitate bolus transfer to a passive bolus flow if necessary. For that purpose, a new myofascial pectoralis flap was designed based on morphometric investigations and postmortal selective injection studies. In this flap, the bulky muscle mass is separated from just a vascularized, thin fascia-muscle layer. The donor site is covered with the remaining bulky muscle-skin complex left intact. The fascial flap covers defects where a soft lining is required and replaces the PE segment as a tubed neopharynx. Histologic specimens show a reepithelization with local mucous membrane from the anastomotic site to the fascial surface. The resistance to bolus flow is reduced, thus alleviating the tongue driving force, which is increased for compensation in any case.

[Digital subtraction dacryocystography (DS-DCG) and evaluation of results of endonasal lacrimal duct surgery]. / Digitale Subtraktions-Dakryozystographie (DS-DCG) und Ergebnisbilanz endonasaler Tränenwegschirurgie.

103 patients with obstructive epiphora, or illacrimation, underwent endonasal lacrimal surgery (dacryocystorhinostomy in the modification of Veis-Cdlaus and canaliculorhinostomy). Postoperative complications included local infections and were seen in 7 cases (6.8%). After finishing the treatment 90 patients (87.4%, Table 4) were free of symptoms and remained so for years of follow-up. Recurrent stenosis developed in 13 cases (12.6%). DS-DCG provides valuable information for confirming the indication for surgery and determining the surgical procedure in obstructive epiphora. In addition it may help to assess a successful outcome of the operation in the course of treatment (Fig. 7 and 8). By means of real time substraction the successive opacification is visualised on the monitor screen during injection thus controlling the examination. Incomplete contrast filling and overopacification are avoided. Digitalisation may direct the extent of homogenisation of the background of the radiographic image. Anatomical structures are preserved and weakly contrasted structures are depicted precisely and independent of the background. Stenoses before (Fig. 2 and 3), within (Fig. 4) and behind (Fig. 6) the lacrimal sac can be differentiated from complete, incomplete (Fig. 4) and functional stenoses.

[HIV-associated parotid cysts]. / HIV-assoziierte Parotiszysten.

20 seropositive HIV patients were examined for the detection of parotid cysts by means of B-mode sonography. In three cases bilateral cysts were found, in three cases unilateral. Only one patient showed clinical symptoms with a bilateral and painless parotideal mass. The cysts were 0.32 to 3.8 cm in diameter. No correlation could be found, neither to the CDC-classification (according to the Center for Disease Control) nor to different HIV-related lesions. Pathogenesis, diagnostic procedure, and clinical relevance of this new entity are discussed. HIV-seropositive patients should be examined sonographically for detection of parotid cysts as indicators for early manifestation of a HIV infection. It is recommended that in patients having cervical sonography for any reasons, a hidden HIV-infection should be excluded once cystic parotideal lesions have been detected.

[Immunoscintigraphic detection of metastasis in malignant melanoma in the head and neck area]. / Immunszintigraphischer Metastasennachweis bei malignen Melanomen im Kopf-Hals-Bereich.

The value of immunoscintigraphy in patients with metastatic malignant melanoma of the head and neck is compared with clinical, radiological and histological findings. 25 immunoscintigraphic examinations in 16 patients were evaluated. Scintigraphy was performed during primary and follow-up diagnosis of head and neck melanoma of the skin (n = 8), nose and sinuses (n = 3), petrosal bone (n = 1) and sclera (n = 1) as well as in cervical lymph node metastases of distant melanoma (n = 2) and melanoma of an unknown primary tumour (n = 1). Immunoscintigraphy was performed with 99mTc-radiolabelled melanoma specific antibodies against a melanoma-associated cell membrane-bound antigen (glycopolypeptide). The sensitivity of the method was 88%, specificity was 80%. The prior significance of immunoscintigraphy is based on the detection of occult cervical lymph node metastases not detectable by means of palpation and radiography. Pulmonary and liver manifestations could not be safely identified due to the physiological enhanced blood pool in these organs. The results obtained indicate that immunoscintigraphy may yield more information about the status of pathologically altered tissue and in certain cases may influence the therapeutic procedure.

[Pre-auricular angiomyxoma in a child]. / Präaurikuläres Angiomyxom beim Kind.

Myxomas are rare benign tumours in adolescents and adults with a predominant manifestation in the region of the maxillary and mandibular bone. A case of a cystic, slowly growing tumour in the right preauricular region is presented. During operation the tumour was completely encapsulated by connective tissue and showed a lobular shape on the cut surface with small cystic cavities. Histologically a myxomatous tissue was seen with a prominent and reticular capillary system like an angiomyxoma. The pathogenesis remains unclear. The definite diagnosis is established by histology. Histological and immunohistochemical differentiation between different benign mixed tumours should include myxomatous neurinomas and lipomas as well as myxomatous transformed histiocytomas. Surgery is the treatment of choice. After a follow-up for more than two years the patient is free from clinical symptoms.

[Treatment of laryngotracheal papillomatosis with combined use of laser surgery and intralesional administration of alpha-interferon (Roferon)]. / Behandlung der laryngotrachealen Papillomatose mit kombinierter Anwendung von Laserchirurgie und intraläsionaler Applikation von Alpha-Interferon (Roferon).

Since the discovery of a viral aetiology (HPV 6 and 11), alpha-interferon (alpha-IFN) following surgical procedures has proved effective. In this article, we report on nine patients (four children, five adults) with laryngotracheal papillomatosis who received interstitial alpha-2a-IFN injections (Roferon, 3 Mio. IU) into the laser surgical coagulation area following laser excision of papilloma. The average duration of treatment is 29 months (Table 3). In all cases IFN therapy proved to respond with no initial failure. In five cases the treatment was finished after a four-year period with no signs of tumour recurrence (Table 4). One patient (N., P. in Table 4) with excessive manifestations spread over pharynx, larynx and trachea achieved partial remission with definite control over the disease for (so far) 17 months. Two patients have remained free of disease for five and seven months (J., D. in Table 4 and Fig. 1 a-c) after initial therapy onset with complete remission. Another child (W., F. in Table 4) had a recurrence after complete remission for ten months and no observation period for eight months. After recurrent IFN-application this patient has been tumour-free for now six months. Apart from flu-like symptoms no side effects of intralesional IFN-injections could be seen. The obtained results confirm that combined laser surgery and alpha-IFN treatment is the therapy of choice up to now. Since IFN is not a benign agent and systemic administration bears potential side effects, adjuvant intralesional alpha-IFN is effective and safe and extends the therapeutical possibilities available in laryngotracheal papillomatosis.

Tumor markers in the diagnosis and follow-up of head and neck cancer: role of CEA, CA 19-9, SCC, TK, and dTTPase.

The clinical relevance of the carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, squamous cell carcinoma antigen (SCC), thymidine kinase (TK), and deoxythymidine-5'-triphosphatase (dTTPase) as tumor markers in the diagnosis and follow-up treatment of 26 patients with head and neck cancer is evaluated. Serum levels prior to treatment were found elevated just above the upper limit of normal in 46% (SCC), 15% (CEA), 12% (CA 19-9), 27% (TK), and 39% (dTTPase) of all patients. If all markers were taken into account, they were elevated in 73% of the untreated patients. However, only in a few cases were the tumor marker values elevated significantly (8%-12%). No significant correlation was detected between serum levels and tumor localization, staging, grading, or performance status for any of the markers. In the follow-up none of the markers tested revealed any disease-related information despite therapy variation. Patients with originally elevated marker levels showed decreasing and in some cases increasing values after primary therapy, although no tumor recurrence was detected. Even considering the results as preliminary due to the rather small sample size, they suggest that the routine assessment of CEA, CA 19-9, SCC, TK, and dTTPase serum levels is of limited practical value.