[Injuries of the head and neck in suicidal intention]. / Verletzungen des Kopfes und des Halses in suizidaler Absicht.

BACKGROUND: Injuries of the head and neck with suicidal intention might create serious situations that require rapid and interdisciplinary treatment. METHODS AND PATIENTS: Twenty-seven patients with suicidal head and neck injuries were treated at the Department of oto-rhino-laryngology, head and neck surgery, University of Wurzburg/Germany, between 1991 and 2002. The medical histories were analyzed retrospectively. RESULTS: Twenty-three of them were male, 4 female. Mean age at time of attempted suicidal was 48 years (18 - 90). One patient was already treated for a psychiatric disorder. None of the patients had a suicidal attempt in the history. Nine patients suffered from a pharynx or larynx trauma after strangulation. Four out of seven patients with cutting or stabbing injuries showed a perforation of the upper airways. Nine patients had gunshot traumas, one of them with perforation of the pharynx. Thirteen patients underwent immediate endoscopy under general anaesthesia followed by a neck exploration in 3 patients. Six patients received a temporary tracheotomy. All patients were considered suicidal for the duration of stay in the ENT-department resulting in a permanent supervision. All patients were transferred to a psychiatric unit as soon as possible for further treatment. A statistically significant accumulation was observed during the last third of a year. Over the period of 11 years, suicidal injuries of the head and neck tend to occur more frequently. CONCLUSIONS: The presented study emphasizes the need of immediate surgical and intensive care treatment of patients with head and neck injuries due to suicide attempts as well as an adequate psychiatric supervision during as well as after the surgical treatment.

[Deep neck infections and mediastinitis]. / Tiefe Halsinfektionen und Mediastinitis. Eine schwerwiegende Komplikation nach schwieriger endotrachealer Intubation.

Deep neck infections and subsequent mediastinitis can occur as lethal complications after endotracheal intubation. A 53 year old female patient developed a neck abscess and mediastinitis due to esophageal perforation after endotracheal intubation. Neck and mediastinal exploration were performed as primary surgical treatment in cooperation with thoracic surgeons. Drainage tubes for neck and mediastinum were inserted and irrigated frequently. The abscess cavity was re-examined twice after primary surgery. Microbiological tests were performed at regular intervals to guarantee appropriate antibiotic therapy. This case demonstrates the importance of early and extensive surgical intervention and the necessity of interdisciplinary cooperation in treating such infections.

[Surgery of anterior skull base fractures]. / Operative Versorgung von Verletzungen der Frontorhinobasis.

BACKGROUND AND METHODS: The medical records of 144 patients that underwent surgery due to fractures of the anterior skull base between 1990 and 1999 were assessed retrospectively. Fracture causes, symptoms, fracture lines, surgical approaches and materials for dura repair were analyzed. RESULTS: The most frequent fracture causes were automobile (46.1%), recreational (24.8%) and occupational accidents (16.3%). While a decrease in automobile accidents was observed from 1996 (71.4%) to 1999 (33.3%), an increase in sports accidents was documented from 1990 (5.3%) to 1999 (16.7%). The most common accompanying injuries were CSF leakage (38.9%), loss of vision (28.5%) and intracranial bleeding (21.5%). The roof of the ethmoid sinus (79.7%) and the frontal sinus (anterior and posterior wall) (73.6%) were fractured most commonly. The lamina cribrosa was involved in 32.6%, the sphenoid sinus in 29.2% of the fractures. Most commonly the bitemporal Unterberger approach (75.7%) was used. To a lesser degree the uni- (13.9%) or bilateral (4.8%) Kilian approach, the reopening of the old wound (4.2%) and the endonasal approach (1.4%) were utilized. Conserved dura was applied for the closure of CSF leaks in 80.7%, periostal flaps in 20.7%, fascia lata in 14.8% and TachoComb in 8.2%. CONCLUSIONS: The results of this study indicate that posttraumatic fractures of the anterior skull base are declining in frequency. The most common causes for these injuries were automobile accidents but increasingly sports accidents. Typical fracture lines or combinations were not observed. In the period observed the bitemporal Unterberger approach and resorbable implant materials such as the coated collagen fleece TachoComb were increasingly used for surgery.

[Paranasal sinus surgery in chronic sinus disease and benign tumors indications, concepts and complications at a teaching institution]. / Chirurgische Eingriffe an den Nasennebenhöhlen bei Sinusitiden und benignen Tumoren. Indikationen, Konzepte und Komplikationen einer Weiterbildungseinrichtung.

BACKGROUND AND METHODS: The medical records of 635 patients that underwent paranasal sinus surgery for chronic sinus disease or benign tumors during a 6.5 year span were assessed retrospectively to evaluate the status of sinus surgery at a teaching institution. The parameters analyzed were indication for surgery, surgical approach, extent of the procedures and complications. RESULTS: The ratio between male and female patients was 2 : 1, with an average age of 44 (+/- 16) years. In 137 cases (21.5 %), revision surgery in patients previously treated at the University of Wuerzburg was necessary. In 80 cases (12.6 %), prior surgery had been performed elsewhere. The majority of the procedures (91.3 %) were carried out using endonasal techniques. External, transethmoid (6.5 %) or transmaxillar (2.2 %) approaches were chosen in 8.7 % of all cases, mainly when the preoperative diagnoses were mucoceles (65.2 %), benign tumors (40.9 %) or orbital complications (33.3 %). Surgery was assisted exclusively by the microscope in 78.7 %, solely by the endoscope in 15.9 % and with a combination of both optical tools in 5.4 % of all cases. The total rate of complications was 8.2 %. Minor complications were seen in 8.1 % of the endonasal and 4.9 % of the external transethmoid procedures. While no major complications occurred during endonasal or extranasal transmaxillar surgery, liquorrhoe was documented in three extranasal transethmoid procedures (7.3 %). Neither permanent impairment of vision, nor post-operative meningitis nor surgery-related mortality was observed in any case. CONCLUSION: The study gives an overview over the paranasal sinus surgeries performed at a teaching institution, independent of the experience of the surgeon. It confirms the results of previous investigations and indicates that endonasal sinus surgery is a reproducible and reliable procedure that can be safely applied at a teaching institution. The results also show that the indication for extranasal approaches is further reduced to the less invasive endonasal techniques.

[The effects of quinine on active motile responses and fine structure of isolated outer hair cells from the Guinea pig cochlea]. / Der Einfluss von Chinin auf aktive Motilität und Feinstruktur isolierter äusserer Haarzellen der Meerschweinchenkochlea.

BACKGROUND: Large doses of quinine (as well as of salicylate) are known to produce reversible hearing loss and tinnitus. Cochlear outer hair cells seem to be the common site for the ototoxic effect of both drugs. METHODS: Isolated outer hair cells from the guinea pig cochlea were exposed to ototoxic doses of quinine hydrochloride (0.05-1.5 mmol/l). The cells were examined using tight-seal whole-cell recording techniques and transmission electron microscopy. RESULTS: Quinine exposure led to a hyperpolarization followed by a depolarization of the hair cells' membrane potential. It also caused a diminution of evoked rapid motile responses that was more apparent in response to hyperpolarizing than to depolarizing pulses. These effects were largely dose dependent and reversible. Ototoxic doses of quinine were not found to induce changes in turgor, shape or fine structure of outer hair cells such as those reported with ototoxic doses of salicylates in vitro. CONCLUSIONS: The present in vitro findings show that quinine (as well as salicylate) directly and reversibly affects cochlear outer hair cells. They also indicate that the underlying mechanisms of quinine ototoxicity are considerably different to that of salicylate although both substances clinically lead to identical symptoms.

[Universal newborn hearing screening program in Würzburg. Experience with more than 4000 newborns and the influence of non-pathological factors on the test results]. / Das Würzburger Hörscreening-Programm bei Neugeborenen. Erfahrungen bei mehr als 4000 Säuglingen - Einfluss nichtpathologischer Faktoren auf die Messergebnisse.

BACKGROUND: The BERAphon(R) method employing a special headphone and the time-course step-stimulus algorithm offers a quick and reliable tool for universal hearing screening in newborns. An ABR-based universal newborn hearing screening program has been established in Würzburg since August, 1997. Until August 2001, 4115 newborns have undergone primary and/or control-screening with the BERAphon(R). The validity of this method was further examined by testing the effects of non-pathological factors such as gender, age, Apgar score, pH value of the umbilical cord, head circumference and duration of pregnancy on the ABR wave V latency in 415 infants. RESULTS: Out of 3930 infants who were primary screened, 27 infants were diagnosed to have hearing loss. Furthermore, hearing loss was detected in 35 out of 185 infants referred for control screening. Non-pathological factors showed a minor effect on the test results. Apgar score, gender or chronological age did not have any significant effects on the latency of wave V. Duration of pregnancy, pH value of the umbilical cord or head circumference showed a significant but weak correlation with wave V latency. CONCLUSIONS: Only non-pathological factors related to maturation had a minor effect on ABR measurements using the time-course-step-stimulus algorithm. The BERAphon(R) method has proven to be a reliable, robust method giving information related to the hearing threshold and accordingly can be used reliably for hearing screening in newborn infants.

[Detection of loudness recruitment in patients with retrocochlear lesions using the "Würzburger Hörfeld" loudness scaling]. / Rekruitmentnachweis bei retrokochleären Raumforderungen mit der Lautheitsskalierung im "Würzburger Hörfeld".

BACKGROUND: The pathogenesis of hearing loss caused by cerebellopontine angle tumors such as acoustic neuromas is unknown. The lack of loudness recruitment is thought to be one of the features of retrocochlear hearing impairment. In contrast to conventional suprathreshold tests, the categorial loudness scaling using the "Würzburger Hörfeld" is a valuable tool to describe the individual perception of sound. The aim of the present study was to analyze the loudness growth rate in patients with acoustic neuroma. PATIENTS AND METHOD: Pure tone and speech audiometry as well as auditory brainstem response and bilateral categorial loudness scaling were performed preoperatively in 54 patients with acoustic neuroma. Loudness scaling was done in free field switching off the contralateral ear by using an ear-plug. RESULTS: An abnormal rapid loudness growth function was found in 38 of the 54 patients (70.4%) at least at one frequency on the tumor side. The contralateral side was effected only in 57.4% of the patients. The incidence of a recruitment depended on the frequency with a maximum at 4 kHz. The slope of the loudness function showed a tendency to increase with increasing hearing loss. CONCLUSIONS: Loudness recruitment is not a rare phenomenon in patients with acoustic neuroma. The underlying cause (a preexisting hair cell damage, hair cell changes resulting from an obstruction of the cochlear blood supply or a disruption of the cochlear efferents) still remains unclear.

Transient evoked and distortion product otoacoustic emissions following successful stapes surgery.

BACKGROUND: The effect of stapes surgery on the recording of otoacoustic emissions is unknown. The aim of the present study was to evaluate the success of stapes surgery by using acoustically evoked otoacoustic emissions as an objective and fast method for postoperative hearing evaluation. METHODS: Transient evoked (TEOAE) and distortion product otoacoustic emissions (DPOAE) were measured consecutively in otosclerosis patients before as well as 3 and 6 months after stapes surgery. RESULTS: Air-bone gaps in the pure-tone audiograms were significantly reduced in all patients. TEOAEs and DPOAEs were not measurable preoperatively and were only evident in one patient postoperatively with low amplitudes in a narrow frequency range. CONCLUSIONS: Despite a subjective hearing improvement and a significant reduction of the conductive loss, otoacoustic emissions are only rarely evident after successful stapes surgery.

[Diving medicine aspects in otorhinolaryngology. II. Diving-specific illnesses and dysfunctions as well as assessment for diving fitness]. / Tauchmedizinische Aspekte in der Hals-Nasen-Ohrenheilkunde. II. Tauchspezifische Erkrankungen und Funktionsstörungen sowie Tauchtauglichkeitsuntersuchung.

Scuba diving with compressed air has become a recreational sport that can be performed at all stages of adulthood. The human body including all gas-filled cavities are exposed to an increased ambient pressure during a dive. In the present review article, specific aspects of diving related disorders are that are of importance in the otolaryngology field are presented and discussed: the multitude of causes for divers' vertigo and the so called divers ear. Furthermore, useful recommendations in the assessment of physical fitness for diving are presented. This review will provide a background and foundation for both, an adequate treatment of these diseases and a critical and responsible health education of the diver.

["Vibrant Soundbridge" middle ear implant for auditory rehabilitation in sensory hearing loss. I. Clinical aspects, indications and initial results]. / Das Mittelohrimplantat "Vibrant Soundbridge" zur Hörrehabilitation bei sensorischer Schwerhörigkeit. I. Klinik, Indikation und erste Ergebnisse.

BACKGROUND: The adequate therapy for patients suffering from a sensory hearing loss consists of fitting electronic hearing devices. Conventional hearing aids, however, present with significant inherent drawbacks such as insufficient amplification in the high frequency range, problems with the ear mold (feed back, occlusion, external otitis), or distortion of sound with an "unnatural" hearing impression. METHODS: The partially implantable middle ear device Vibrant Soundbridge provides a sound wave conversion into mechanical vibrations at the middle ear ossicles using the Floating Mass Transducer (FMT). The audiological advantages are due to a direct moving force to the perilymph via incus and stapes. The Vibrant Soundbridge system is indicated in patients with a medium to severe symmetrical sensory hearing loss and a normal middle ear. Candidates need previous experience with conventional hearing aids without satisfactory results. RESULTS: The eight operated patients report a "natural" quality of sound and speech, a better hearing perception at high frequencies and the absence of feed back phenomena. Audiological evaluation and questionnair results support the patients subjective hearing impression. CONCLUSIONS: The Vibrant Soundbridge improves hearing quality in patients with sensory hearing loss. The hearing implant is indicated in particular in patients that are unable to wear conventional hearing aids.

[Universal hearing screening of newborn infants with the BERA-phone]. / Universelle Hörscreening-Untersuchungen bei Neugeborenen mit dem BERAphon.

BACKGROUND: Unidentified and untreated early infant hearing loss leads to speech-language deficits as well as to cognitive, intellectual, emotional and psychosocial handicaps. Targeted hearing screening programs may miss approximately 50% of all hearing impaired children. METHODS: In an universal hearing screening program with a two stage protocol, 1349 newborns were examined using the CRESCENDO Newborn Hearing Screener according to Finkenzeller and a clinical ABR system operating with a time course step stimulus algorithm. RESULTS: Five newborns that failed the two stage screening protocol were diagnosed as hearing impaired so that therapy was initiated before the age of six months. The specificity of the method was 98.8%. The CRESCENDO method only required a short examination time and was easy to apply. CONCLUSIONS: Hearing screening programs using ABR offer advantages when compared to evoked otoacoustic emission testing. ABR threshold detection with the time course step stimulus algorithm is a quick and easy to apply method with high specificity that can be recommended for newborn hearing screening.

[An anesthesia technique for experimental studies and microsurgical ear interventions in newborn rodents]. / Eine Narkosetechnik für experimentelle Untersuchungen und mikrochirurgische Eingriffe am Ohr neugeborener Nagetiere.

BACKGROUND: Experimental investigations on laboratory animals usually require sufficient anesthesia with adequate analgesia and sedation. The technique used should be reliable and easily controllable by the investigator. Here, we present a technique for anesthesia to facilitate invasive and noninvasive investigations in newborn rats and mice. METHODS: Using a custom made breathing mask, anesthesia was induced in these animals with inhalation of gaseous nitrous oxide-oxygen (equal volume at 1 l/min) and halothane (3% by volume). To maintain anesthesia, halothane insufflation was reduced to 1-1.5% by volume. After completion of the experimental procedure, the application of the inhalative gases was determined and substituted by oxygen at 2 l/min. Anesthesia was performed in spontaneously breathing animals. Heart frequency and oxygenation were monitored using a commercially available pulse oximeter. RESULTS: Using the above described technique in neonatal rodents, microsurgery of the ear was performed without signs of pain or major bleeding. Auditory brain stem responses were recorded clearly and reproducible. CONCLUSIONS: This method represents a noninvasive, well tolerated and easy controllable anesthetic procedure which has proven to provide a sufficient and reliable sedation in neonatal rodents for surgical and nonsurgical investigations.

[Medical aspects of diving in otorhinolaryngology. I. Barotrauma and decompression sickness]. / Tauchmedizinische Aspekte in der Hals-Nasen-Ohrenheilkunde. I. Barotrauma und Dekompressionskrankheit.

Recreational scuba diving has become immensely popular in recent years and is no longer restricted to individualists or adventurers. During a dive, the human body with its gas-filled cavities is exposed to an increased ambient pressure. In the present review article, aspects of diving and hyperbaric medicine related to the otolaryngology field are presented. The basics of physics, physiology and pathophysiology that are essential to understand the effects of an increased and varying ambient pressure are reviewed. Barotrauma of the outer, middle and inner ear, the paranasal sinuses, face, teeth and larynx are explained and classified in those during the compression and decompression phase. This is followed by a discussion of inner ear decompression sickness. The present article will provide a background and foundation for both, an adequate treatment of these diseases and a critical and responsible health education of the diver.

[Intra- and intersubject variability of acoustically evoked otoacoustic emissions. I. Transiently evoked otoacoustic emissions]. / Intra- und interindividuelle Variabilität akustisch evozierter otoakustischer Emissionen. I. Transitorisch evozierte otoakustische Emissionen.

BACKGROUND: Acoustically evoked otoacoustic emissions are becoming increasingly significant in the clinical monitoring of cochlear function in adults. Any interpretation of these measurements in a clinical setting must consider their intra- and intersubject variability. METHODS: Transiently evoked otoacoustic emission (TEOAE) measurements were performed in 32 normally hearing adults in three weekly test sessions. Each ear was tested twice per session, and the results were statistically analyzed. RESULTS: All test candidates had measurable TEOAEs. Statistically significant differences in TEOAE amplitudes were neither found between two measurements at the same day, nor at weekly intervals. No statistically significant amplitude differences were found between right and left ear of the same candidate. TEOAE amplitudes in women were always higher than in men with statistically significant differences in the 2, 3, and 4 kHz frequency band. CONCLUSIONS: These results indicate that monitoring of the inner ear status can be reliably performed using TEOAE measurements. Changes in TEOAE amplitudes effectively indicate changes in the cochlear function.

[Intra- and intersubject variability of acoustically evoked otoacoustic emissions. II. Distortion product otoacoustic emissions]. / Intra- und interindividuelle Variabilität akustisch evozierter otoakustischer Emissionen. II. Distorsionsprodukt-Emissionen.

BACKGROUND: Distortion product otoacoustic emissions (DPOAEs) are evoked by simultaneously stimulating the cochlea with two tones. The DPOAE with the highest amplitude (at the frequency 2f1-f2) is usually used for routine audiological evaluation. Any interpretation of DPOAEs in a clinical setting must consider their intra- and intersubject variability. METHODS: DPOAE measurements were performed in 36 normally hearing adults in three weekly test sessions. Each ear was tested twice per session, and the results were statistically analyzed. RESULTS: All test candidates had measurable DPOAEs. Statistically significant differences in absolute DPOAE amplitudes were neither found between two measurements at the same day, nor at weekly intervals, nor between right and left ear of the same candidate. Absolute DPOAE amplitudes in women were significantly higher in the 2-6 kHz range whereas they presented with significantly lower amplitudes below 2 kHz when compared to men. CONCLUSIONS: The present results indicate that monitoring of the inner ear status can be reliably performed using DPOAE measurements. Change in DPOAE amplitudes effectively indicate changes in the cochlear function with high sensitivity. Compared to TEOAE measurements, DPOAEs offer a higher frequency resolution in a broader frequency band and thus more detailed information about the cochlear condition.

[Long-term outcome after reconstruction of the cranial base with ionomer cement]. / Langzeitergebnisse nach Rekonstruktion der Schädelbasis mit lonomerzement.

BACKGROUND: Congenital, posttraumatic, inflammatory or tumours skull base lesions with CSF leakage require reconstruction to mechanically stabilize the CNS and to securely seal the CSF space. PATIENTS AND METHODS: Ionomeric cement was used from 1988 until 1994 in 44 patients for skull base reconstruction at the Department of Otolaryngology-Head and Neck Surgery, University of Würzburg. Thirty-five patients were reexamined. The longest follow-up time was 8 years. The program for the present follow-up study comprised a general ENT and neurological examination as well as CT scans of the skull base, MRI tomography of the CNS, and the determination of the aluminium plasma concentration. RESULTS: None of the patients reexamined presented with complaints. Neurological examinations and MRI tomography in all patients did not reveal any pathological finding related to ionomeric cement application. Aluminium plasma concentrations in patients who received ionomeric cement implantations were not significantly elevated when compared to controls. General ENT examinations and CT scans in thirty-two patients demonstrated regular postoperative findings. The cement at the anterior skull base was not covered completely by mucosa in three patients. In one these cases, CT scans revealed dislocation of the ionomeric cement so that revision surgery was performed for removal. None of the patients to date presented with a CSF leak. CONCLUSION: Long-term results of the present study show that ionomeric cement is a suitable material for closure of osseous skull base lesions to permanently seal the CSF space. These results, however, can only be obtained when handling and application of the material is adequate. Unfortunately, the production of ionomeric cement has been stopped since 1995 following four cases of aluminium encephalopathy reported in the literature.

Stapes surgery in osteogenesis imperfecta patients.

Osteogenesis imperfecta (OI), or the Van der Hoeve-de Kleyn syndrome, is a heterogeneous group of connective tissue disorders. The key features in this disease are bone fragility with a tendency to spontaneous fractures and deformations. The classical traid of symptoms involves a conductive and/or sensorineural hearing impairment together with a tendency to spontaneous bone fractures and blue sclerae. Between January 1988 and December 1994, ear surgery was performed on eight ears of six OI patients who presented with mixed hearing loss preoperatively. Pathological changes observed in the middle ear were atrophy and/or fractures of the stapedial crura in combination with thickening and fixation of the stapes footplate. Partial stapedectomy was performed in seven cases and a neo-window was created in the promontory of one patient when an overhanging facial canal obscured visualization of the oval window niche. Pre- and postoperative bone conduction thresholds did not differ in any of the patients. Postoperatively, mean values of the air-bone gap in the main speech frequency range were below 10 dB. Functional results following stapes surgery in patients with otosclerosis during the same time interval (n = 857) did not differ significantly. These data indicate that stapes surgery in OI patients can be performed with the same functional predictability as in otosclerosis patients, even though the underlying etiology is considerably different.

Immunohistochemical and fine structural characterization of primary carcinoid tumors of the larynx.

Carcinoid tumors belong to the group of neuroendocrine tumors of epithelial origin, i.e., neuroendocrine carcinomas. These neoplasms usually occur in the gastrointestinal tract or bronchial system but are very rare neoplasms in the larynx. Since carcinoid tumors in this latter site may appear to be undifferentiated by light microscopy, they may possibly be misinterpreted and their neuroendocrine characteristics may remain unrecognized. Using immunohistochemical methods, three carcinoid tumors were studied and showed positive immunostaining for markers of epithelial origin (cytokeratins, epithelial membrane antigen, carcino-embryonic antigen) and, in particular, for markers of neuroendocrine differentiation (chromogranin, synaptophysin, neuron-specific enolase). All tumors expressed calcitonin-, serotonin- and adrenocorticotropic-hormone-like immunoreactivity. In contrast, three poorly differentiated squamous cell carcinomas showed positive immunostaining for epithelial markers but did not show any immunoreactivity with markers of endocrine characteristics. Fine structurally, carcinoid tumor cells contained neurosecretory-type granules scattered throughout the cytoplasm. The present study demonstrated that (1) carcinoid tumors of the larynx possess distinct immunohistochemical characteristics that allow a clear classification, (2) it is advisable to use a battery of primary antibodies rather than rely on specificity and sensitivity of a single marker to establish diagnosis and (3) the fine structural demonstration of neurosecretory-type granules serves as a reliable adjunct to diagnosis.