[Primary sinu-nasal melanomas. Clinical aspects, therapy and follow-up]. / Primäre sinunasale Melanome. Klinik, Therapie und Verlauf.

BACKGROUND AND OBJECTIVE: Primary malignant melanoma of the nasal cavity and paranasal sinuses is a rare entity felt to have a poor prognosis. We examined the frequency and characteristics of this type of melanoma in a defined geographic region over a period of 16 years. PATIENTS/METHODS: Nine patients (eight men, one woman, mean age 62 years) with primary nasal and sinusoidal malignant melanoma were treated between 1985 and 2000 in the Department of Dermatology in cooperation with the Department of Otorhinolaryngology. All patients underwent surgery, eight with clinical complete tumor removal and one with only partial removal. All patients had radiotherapy after surgery. History, potential risk factors, clinical presentation, histological and immunohistochemical data and clinical course were documented. RESULTS: All patients died because of their tumor within the observation period (median survival: 30 months, range 7 to 75 months). There were three different courses of the disease: (1) uncontrollable primary tumor (one patient, survival 11 months); (2) local recurrence with metastasis (five patients, median survival 40.2 months); (3) metastasis after a disease-free interval (three patients, median survival 19.3 months). CONCLUSIONS: Malignant melanoma of the nasal cavity and paranasal sinuses is a rare entity which is usually rapidly fatal. Effective treatment approaches are not available.

[Diagnosis and therapy of stapes fractures and luxations]. / Diagnose und Therapie bei Stapesfrakturen und -luxationen.

BACKGROUND: Injuries of the ossicular chain have various etiologies. Skull traumas from blows to the temporal, parietal or occipital region with or without fracture of the temporal bone are the main causes of the ossicular injury; other modes of injury are rare. It depends on the type of trauma which kind of injury occurs. Mainly subluxations, luxations and fractures are to be observed. The incus is the ossicle which is the most often injured. Mostly, only one ossicle is injured, rarely two or all of them. PATIENTS: From January 1997 to June 1999 we operated 19 patients with traumatic lesions of the membrane and the middle ear. In 4 cases the reason for the operation was an injury of the stapes. We observed 2 cases with broken stapes crura, 1 case with an impression of the stapes into the vestibulum with perilymphatic fistula and 1 case with subluxation of the stapes in the direction of the promontorium. By presenting 4 cases we want to point out the diagnostic possibilities and the operative management of such rare injuries. In all cases we applied the transmeatal approach for the operation of the middle ear. In 2 cases it was possible to place the stapes back in their anatomic position in order to re-establish the ossicular chain. In the other 2 cases we had to use middle ear prostheses which were interpositioned between the manubrium of the malleus and the footplate of the stapes. RESULTS: In all cases the immediate post-operative hearing results and the long-term hearing results after 10 to 28 months were satisfying. We did not notice any post-operative complications, especially no vestibular symptoms. One patient's tinnitus was the same as before the operation. CONCLUSIONS: The diagnosis of a stapes injury is despite the use of sophisticated technology, especially the CT-scan of the temporal bone, often very difficult. A sensitive anamnesis seems to be very important. It depends on the kind of injury which operative technique is to be applied in order to re-establish the ossicular chain. In our opinion, it is useful to take - if it is possible - the autolog stapes for the surgical re-establishment of transmission.

[Ultrasound investigation of cervical lymph node metastases: conception and results of a histopathological exploration]. / Ultraschalluntersuchung zervikaler Lymphknotenmetastasen: Konzept und Ergebnis einer histopathologischen Aufarbeitung.

BACKGROUND: Ultrasound (US) is one of the most important methods for detection of cervical lymph node metastases in malignancies of the head and neck. In our study, the specificity of ultrasound was explored by a special, histopathological exploration considering the anatomical regions of the neck. METHODS: Thirty-eight patients were studied (5 female, 33 male, age: 38-86 years) with different histology and incidence of metastatic spread of head and neck cancers. Forty-six neck dissections were performed (30 radical and 16 selective). Histological exploration was performed after pinning the neck soft tissue with needles to anatomical live drawings of the lymph node regions, a modification of the Medina procedure. This procedure allowed a correct topographical assignment of lymph node metastases and comparison of preoperative sonographical findings with histopathological results. RESULTS: We isolated 1333 lymph nodes, 137 of them infiltrated by metastases. These lymph node metastases were found in 28 of 46 neck dissections. The number of lymph nodes in radical neck dissections ranged from 21 to 60 (mean: 36), in selective neck dissection from 1 to 43 (mean: 16). Sensitivity, specificity, and accuracy of ultrasound reached 96%, 69%, and 78%, respectively. Seventy-two lymph node metastases (52%) of 12 neck dissections could not be evaluated by ultrasound. CONCLUSIONS: Our results confirm the reliability of ultrasound regarding sensitivity, specificity and accuracy of US-detectable cervical lymph nodes as reported in world literature. However, we were able to demonstrate in special histopathological explorations, that ultrasound did not detect more than 50% of present lymph node metastases in our series. We consider it essential to perform histopathological explorations of the soft tissue of the neck as described in our study to evaluate the efficacy and reliability of US, CT, and MRI in detecting lymph node metastases of head and neck malignancies.

Cystic lymph node metastases of squamous cell carcinoma of Waldeyer's ring origin.

We analysed in a retrospective study the frequency of cystic lymph node (LN) metastases in neck dissection specimens of 123 patients with primary squamous cell carcinoma (SCC) arising in the palatine tonsils (62 M/14 F), the base of the tongue (38 M/5 F) and the nasopharynx (2 M/2 F). Eighty-two per cent of patients had metastases (64 tonsillar SCC, 33 base of tongue SCC and all four nasopharynx SCC) in 368 LN of a total 2298 sampled LN. Thirty-nine per cent of patients had exclusively solid metastases and 37% of patients had exclusively cystic metastases. A total of 62 patients had some signs of cyst formation in one or more metastatically affected LN (27 with only histological evidence of cyst formation with luminal diameters < 5 mm, 35 with clinically detectable cyst with luminal diameter > 5 mm). Cystic metastases were more common in patients with SCC of the base of the tongue (P = 0.005), while solitary clinically evident cystic metastasis with lumina > 5 mm were found exclusively in tonsillar carcinoma (P = 0.024). In comparison with solid metastases, cyst formation was associated with N-categories (N2b and N3, P = 0.005) in SCC of the base of the tongue origin. No such association was observed for tonsillar SCC (P = 0.65). The primary mechanism of cyst formation was cystic degeneration.

Extranodal follicular dendritic cell tumour of the nasopharynx.

We report the first case of an extranodal follicular dendritic cell (FDC) tumour localized in the nasopharynx of a 44-year-old male patient. The tumour cells were characterized immunohistochemically by strong expression of CD21, HLA-DR and vimentin and focal expression of CD68 and cytokeratin. Electron microscopic examination revealed desmosomal cell junctions between adjacent cell processes. Molecular genetic analysis using polymerase chain reaction (PCR) showed germline configuration of immunoglobulin and T-cell receptor genes. Epstein-Barr virus (EBV) genomes were detectable by PCR. After complete surgical tumour removal and radiotherapy the patient is disease-free 20 months after the initial diagnosis.

[Multiplanar angulated 2D reconstruction. A new CT technique for imaging the facial nerve canal]. / Multiplanar angulierte 2D-Rekonstruktion. Eine neue CT-Technik zur Darstellung des Fazialiskanals.

For imaging the facial canal in its tympanic and mastoid segments, a new technique was developed with high-resolution computed tomography (HRCT). This method is based on comparative anatomical studies and makes it possible to depict the course of the facial canal, especially in malformations of the middle ear and in cases of fractures, tumors and cholesteatomas. A longitudinal scan of the petrous part of the temporal bone is obtained by reconstruction based on primary axial CT-standards. In these longitudinal scans the facial canal is shown both in its tympanic and mastoidal segment. For longitudinal reconstruction the scan is orientated through the anterior margin of the carotid canal and petrous pyramid. For evaluating the facial canal in this study, the lateral semicircular canal and stylomastoid foramen are sure landmarks. The sensitivity for evaluating the tympanic segment of the facial canal is 100%. This new technique should be applied in cases in which the exact course of the facial canal must be known preoperatively.

Imaging of the facial canal by means of multiplanar angulated 2-D-high-resolution CT-reconstruction.

The facial canal containing the intratemporal portion of the facial nerve is very important for the otologist and radiologist concerning fractures and other lesions of the temporal bone. Axial and/or coronal standards are sufficient for imaging of the labyrinthine and the mastoidal segment of the facial canal. The sensitivity of visualization (sensitivity = number of identified structures per number of examinations) of the tympanic segment, however, is low and particularly the pyramidal segment (elbow, posterior knee) is not visualized in these standards. Based on anatomical considerations a new plain for imaging both the tympanic and mastoidal segment in continuity was obtained. The pyramido-longitudinal plain is achieved by a twice angulated 2-D-reconstruction based on axial high-resolution CT-scans.

Pretherapeutic scalene lymph node biopsy in ovarian cancer.

To study scalene lymph node involvement in ovarian cancer, 37 patients with this disease underwent pretherapeutic open sampling of the left scalene fat tissue. Only 1 patient had a palpable supraclavicular mass. Positive scalene nodes were found in 7 (22%) of 32 patients with stage III or IV disease. Three of four patients with positive scalene nodes also had both positive pelvic and positive paraaortic nodes; one patient with stage IV disease had negative pelvic and paraaortic nodes. Demonstration of scalene node involvement per se currently does not alter the management of patients with ovarian cancer, although patients with occult involvement of the scalene nodes could be considered ineligible for intraperitoneal chemotherapy.

[Scalenus biopsy in diagnosis of ovarian and uterine cancers]. / Die Skalenusbiopsie in der Diagnostik von Ovarial- und Uteruskarzinomen.

Patients with tumours of the lower pelvis were submitted to a biopsy of the scalene fat pad. The primary tumour was a carcinoma of the ovary in 32, of the cervix in 4, and of the body of the uterus in 2 cases. Microscopic metastases in the pre-scalene lymph nodes were found in 7 of the 32 cases of ovarian carcinoma (21.8%), but in none of the patients with carcinoma of the uterus. Since a histologically positive finding of a scalene lymph node influences the treatment, biopsy of the scalene fat pad is recommended as part of the pre-operative investigation of patients with ovarian carcinoma.

[Differential diagnosis of ulcerative mucous membrane diseases of the mouth cavity and pharynx]. / Zur Differentialdiagnose ulzeröser Schleimhauterkrankungen der Mundhöhle und des Pharynx.

Nonmalignant ulcerous diseases of the mouth often require repeated histological and clinical observations for several weeks to establish a diagnosis. One patient with Wegener's disease, one with a necrotizing sialometaplasia, and a case of Sutton-type aphthosis outline these difficulties. In all three cases, only a synopsis of histology, laboratory findings, and clinical appearance led to the respective diagnosis.

Choristoma of the soft palate.

Choristoma is the pathological term for a developmental tumor-like anomaly consisting of tissues foreign to the site at which it is located. A 3-month-old girl with a choristoma of the soft palate is presented. Its occurrence is extremely rare, as shown by a review of the literature.

[Factors modifying remission in cytostatic chemotherapy of squamous cell carcinoma recurrence in the area of the head and neck]. / Remissionsbeeinflussende Faktoren der zytostatischen Chemotherapie beim Plattenepithelkarzinom-Rezidiv des Kopf-Hals-Bereiches.

From 1981 to 1986 eighty-five patients underwent palliative chemotherapeutic treatment at the E.N.T. Department of the University Hospital in Graz. In seventy-three recurrent tumours comparable RR were achieved with ADM/CDDP as well as with MTX/5-FU. In 39 patients a second treatment after failure or relapse of previous therapy was applied, containing predominantly CDDP/BLM resulting in a RR of 18%. The tumour stage proved to be the single most important factor concerning response to treatment in first as well as second line chemotherapy. Stage IV tumours showed a significantly lower RR compared to neoplasms without large neck masses (stages II, III), the RR being 59% versus 19% (p = 0.01). Furthermore, performance status, preceding therapeutical modalities, and location of the tumours were shown to be of secondary prognostic importance. In the latter group, age and the time interval between recurrences appeared to be of no significance. To evaluate the most effective regimen, highly differentiated analysis of all available data is imperative.

[Stimulation of endogenous defense in cancer patients]. / Beitrag zur Stimulierung der körpereigenen Abwehr beim Krebspatienten.

A group of 45 patients with carcinoma of the larynx who had already been treated were given a sterile dialysate extracted from the sperm of trout to stimulate their endogenous defence mechanisms. Previous research had shown that specially prepared pre-metastatic lymph nodes injected intracutaneously prolonged the average survival time of cancer patients. Similar results could be obtained by using fish extracts. The dermoreaction after the intracutaneous injection showed the patients' susceptibility to stimulation. The patients who reacted positively lived longer than the ones who reacted negatively and those of a homogeneous control group of the same size who were not vaccinated. Survival times and absence of recidivity were significantly longer in patients with supraglottic tumours, stage III.

[Antigenicity of the auricular cartilage and the influence of vital preservation. 2: Identification of antigens of the auricular cartilage: animal experiment studies in rats]. / Die Antigenität des Ohrknorpels und die Beeinflussung durch vitale Konservierung. Teil 2: Nachweis von Antigenen des Ohrknorpels: Tierexperimentelle Untersuchung an Ratten.

We could demonstrate the existence of class I and class II antigens on the chondrocytes of the auricular cartilage in inbred strain rats (Louvain/M/Him, Fischer 344). Indirect fluorescence and related techniques were used. The cartilage was stored in Ham's nutrient medium F 12 or in the tissue culture for 8-10 days before allotransplantation. A complete disappearance of the antigens could not be achieved by means of the vital conservation. Grafting did not modify further the distribution of the antigens; in 2 experiments only renewed strong coloration of the chondrocyte-membranes and the surrounding matrix could be observed.

[Antigenicity of the auricular cartilage and its modification by vital preservation. 1. Xenogeneic transplantation of human auricular concha cartilage to the rabbit]. / Die Antigenität des Ohrknorpels und ihre Beeinflussung durch vitale Konservierung. Teil 1: Xenotransplantation humanen Ohrmuschelknorpels an Kaninchen.

By means of xenotransplantation of human auricular cartilage to rabbits tests were carried out to see, if antigenicity is reduced through storing elastic cartilage either in a nutrient solution (Ham F 12) at 4 degrees C above zero or in a tissue culture (Ham F 12 + 10% serum of a calf-foetus) at 37 degrees C above zero, and if vital preservation prevents degeneration- and resorption processes of cartilage. The results were compared to transplants of fresh, not treated cartilages, and those preserved with cialit and merthiolate. It turned out that these vital preservation methods seem to cause an extensive loss of the cartilages characteristic qualities and that they keep degeneration- and resorption processes at a minimal level. Big differences between storage in nutrient solution and tissue culture could not be observed.

The use of sodium sulfide to separate mercury from tissues preserved in Cialit and Merthiolate solutions.

The purpose of the present experiment was to look at the dissolution time in physiological sodium chloride (0.9% NaCl) and sodium sulfide (Na2S) of any mercury (Hg) contained in human auditory ossicles and cartilage after preservation in Cialit and Merthiolate. Both homograft tissues produced almost identical graph complexes. Under static conditions 10 micrograms Hg could be found in NaCl after 15 min, whereas there was complete demercurization after 3 min in Na2S. The dissolution time in NaCl subjected to constant stirring was about 10 min and was less than 1 min in Na2S. For the rapid elimination of Hg from auditory ossicles stored in preservatives containing Hg, our studies show that the use of a flowing solvent is advisable. Further, the extraction of Hg is quicker in sodium sulfide than in an isotonic solution of sodium chloride.

[Use of allogeneic septal cartilage in the correction of saddle nose]. / Die Verwendung von allogenem Septumknorpel zur Korrektur der Sattelnase.

It is reported about the intraseptal implantation of allogeneic cartilago quadrangularis for the correction of saddle nose in the case of eleven patients. The indication for the implantation were non sufficient residuals of the behind septum for a substitution plastic. The sagging of the noses was caused by iatrogenic in 6 and traumatic influences in 5 cases. The conservation of the septal cartilage was carried out in Cialit 1:5000. All the septa healed in without any reaction and obtained satisfactory functional and cosmetic results.

[Chemotherapy of recurrent squamous cell carcinomas in the ENT area with cisplatin/adriamycin (DDP/ADM) and methotrexate/5-fluorouracil (MTX/5-Flu): a retrospective comparison of 2 protocols]. / Chemotherapie rezidivierender Plattenepithelkarzinome des HNO-Bereiches mit Cis-Platin/Adriamycin (DDP/ADM) und Methotrexat/5-Fluorouracil (MTX/5-Fu): retrospektiver Vergleich zweier Protokolle.

The efficacy of two chemotherapy regimens for recurrent and inoperable squamous cell carcinoma of the head and neck is reported. All patients had failed prior surgery and/or radiotherapy. 23 patients (group A) were treated with Cisplatin 120 mg/m2 and Adriamycin 60 mg/m2. 21/23 were evaluable for tumour response. The overall response rate (RR) was 28.5% (6/21, 2 CR and 4 PR). Methotrexate 250 mg/m2 with Leucovorin-Rescue 5 X 10 mg/m2 and 5-Fluorouracil 600 mg/m2 were administered to 28 patients. In 26 evaluable patients a RR of 38.4% (10/26, 5 CR and 5 PR) was achieved. The responders in groups A and B had a median survival of 98 and 85.5 weeks respectively and the non-responders 27 weeks in both groups. Nausea, vomiting and alopecia were common and severe in the DDP/ADM group. The major toxic effect of MTX/5-FU was neutropenia with two associated deaths from septicemia, although subjective side-effects were almost completely absent. MTX/5-FU can be recommended for the palliative treatment of recurrent squamous head and neck cancer because of an acceptable response rate, good subjective tolerance and the possibility of outpatient treatment.

[Pneumothorax after mediastinal emphysema. The site and mechanism of pleural rupture]. / Pneumothorax nach Mediastinalemphysem. Uber den Ort und den Mechanisms der Pleuraruptur.

By rupture of the mediastinal pleura a mediastinal emphysema may lead to a pneumothorax. An experiment imitating this process is able to point out two spots where the pleura is most likely to tear: An area as large as a thumb tip above the root of the left lung; there mediastinal pleura covers a space the width of which changes most in respirating. The border of a fatty fold based on the pericardium and covered by mediastinal pleura; it is there that maxima of tension occur by emphysematic inflation. In general, air from the mediastinum far more often enters the left pleural cavity than the right one.