Die Behandlung des M. Menière mit Betahistin: Kritische Anmerkungen zur BEMED-Studie.

The BEMED study (BMJ 2016; 352: DOI 10.1136) was designed as multi-centric, double-blind, plaebo-controlled study in patients with Menière's disease. It should compare a low-level (2 × 24 mg/d) vs. high-level (3 × 48 mg/d) betahstine intake vs. placebo. The primary endpoint was the "number of vertigo attacks lasting longer than 20 min as documented in a patient's diary". The main finding of the study was that betahistine did not significantly better reduced the number of vertigo attacks than placebo. Therefore, the BEMED study should be critically discussed in the present paper.

[Implementation of Study Results in Guidelines and Adherence to Guidelines in Clinical Practice]. / Implementierung von Studienergebnissen in Leitlinien und deren Umsetzung in die Klinik.

Guidelines were introduced in hospital and practice-based otorhinolaryngology in the 1990s, and have been undergoing further development ever since. There are currently 20 guidelines on file at the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery. The Society has cooperated in a further 34 guidelines. The quality of the guidelines has been continually improved by concrete specifications put forward by the Association of the Scientific Medical Societies in Germany [Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V.]. Since increasing digitalisation has made access to scientific publications quicker and more simple, relevant study results can be incorporated in guidelines more easily today than in the analogue world. S2e and S3 guidelines must be based on a formal literature search with subsequent evaluation of the evidence. The consensus procedure for S2k guidelines is also regulated. However, the implementation of guidelines in routine medical practice must still be considered inadequate, and there is still a considerable need for improvement in adherence to these guidelines.

[Management of patients with risk factors]. / Management von Risikopatienten.

This review deals with concomitant diseases and risk factors in patients treated for otorhinolaryngologic disease in outpatient and hospital services. Besides heart disease, lung disease, liver disease and kidney disease this article also covers disorders of coagulation (including the therapy with new anticoagulant drugs) of electrolyte hemostasis. Special attention is paid to prophylaxis, diagnosis and treatment of delirium. Also information is provided to optimize preparation of surgical procedures and pharmacotherapy.

[Results of transoral laser resection in T1-2 oropharyngeal, hypopharyngeal and laryngeal carcinomas]. / Ergebnisse der transoralen Laserresektion bei T1-2 Karzinomen von Oropharynx, Hypopharynx und Larynx.

BACKGROUND: Transoral laser microsurgery (TLM) has led to an expansion of the therapeutic modalities for malignomas of head and neck. This study aims to assess the oncologic results and functional outcomes of TLM in early carcinomas. PATIENTS AND METHODS: This is a retrospective study of 947 cases with T1-2 carcinomas primarily managed with laser surgery between 1979 and 2007. All cases were assessed for survival, with respect to location, T and N classification and status of surgical margins. Cases were additionally evaluated for incidence of major complications and retention of laryngeal and pharyngeal function. RESULTS: Disease specific survival was 78.6% for oropharyngeal, 68.9% for hypopharyngeal, 82.3% for supraglottic und 95.2% for glottis carcinomas. Survival estimates were found to be significantly better for cases without cervical metastasis and with negative surgical margins. A low rate of major complications (4.7%) were noted. 1% of the patients had a permanent dysfunction of swallowing and 1.1 % needed a permanent tracheostomy. CONCLUSION: Laser surgery appears to be a very effective management modality for small carcinomas of the head and neck as long as clear surgical margins can be achieved. This technique offers acceptable oncologic results with a low incidence of complications and satisfactory retention of function.

[Traffic medicine expert opinions in otorhinolaryngology: current aspects]. / Verkehrsmedizinische Begutachtung in der HNO-Heilkunde : Aktuelle Aspekte.

According to German law granting of driving licenses depends on the proof of an adequate driving capability. The corresponding guidelines are at present in the process of being revised. At the moment bilateral deafness and high-grade hearing loss (> or = 60% in pure tone audiometry) are not exclusion criteria for driving licenses grades A, B and C, while driving licenses grade D and licenses for public transport are generally excluded. In the forthcoming revised edition of the guidelines it has been suggested that the latter group will also not be excluded. The regulations concerning dizziness are wide-sweeping at the moment as no driving license will be granted if dizziness is present but will be more specific in the next issue. In particular a division will be made between single axle and two axle vehicles. An expert assessment about driving suitability can only be made by a certified specialist with qualifications in traffic medicine.

Evaluation of the revised TNM classification in advanced laryngeal cancer.

The latest revision of the UICCs TNM classification in 2002 subdivided advanced laryngeal carcinoma into the subcategories T4a and T4b, in order to emphasise the poor prognosis and inoperability of the latter group. Our study aims at evaluating the prognostic relevance of this subclassification. This retrospective analysis includes 163 patients treated for advanced laryngeal carcinoma between 1980 and 2002. The disease-free 5-year-survival rates for patients suffering from T4a and T4b laryngeal carcinoma were 32.4 and 6.7%, respectively (P = 0.003). The T-category and free margins proved to be significant prognostic factors. The survival of patients suffering from T4a carcinoma proved to be independent of specific location and number of invaded structures. This study confirms the much poorer prognosis for patients suffering from T4b carcinoma and thus supports the modified TNM classification.

[Lymph node metastasis of glottic laryngeal carcinoma]. / Die Halslymphknotenmetastasierung des glottischen Larynxkarzinoms.

UNLABELLED: The incidence of lymph node metastases in glottic cancer is assumed to be lower than in other head and neck cancers. In a retrospective study this statement was investigated. MATERIAL AND METHODS: This analysis was based on 910 consecutive patients with glottic carcinoma treated between 1970 and 1990 by means of surgery with special interest on regional lymph node metastases. RESULTS: 8.6 % patients had clinically positive necks (N+) and 5.9 % pathohistologically positive necks (pN+). The incidence of lymph node metastases showed correlation with pT category and vocal cord mobility. Lymph node metastases were found in 5 % of pT2, in 18 % of pT3 and in 32 % of pT4 tumors. Only one patient with pT1 cancer had metastatic lymph node involvement. The incidence of occult lymph node metastases was 18 %. Lymph node involvement, extracapsular spread and lymphangiosis carcinomatosa proved to be relevant prognostic factors. The 5 year recurrent free survival rate was 86.7 % for the whole group, 81.6 % for patients with negative nodes (pN0), and 61.8 % for patients with pN+ nodes (p < 0.001 according to logrank test). CONCLUSIONS: Clinical lymph node staging plays an important prognostic role in the staging procedure also in glottic carcinoma. At least in T3 carcinomas, elective treatment of the cervical lymph nodes seems to be necessary. T2 carcinomas with impaired cord mobility have a significant higher risk for metastatic spread; therefore neck dissection should be discussed also in these cases.

[Findings in a high-risk group following asbestos exposure. Benefit of ENT examinations in patients with long-term exposure to asbestos]. / Befunde in einem Hochrisikokollektiv nach Asbestexposition Nutzen von HNO-ärztlichen Untersuchungen ehemals asbeststaubexponierter Personen.

BACKGROUND AND OBJECTIVE: Laryngeal diseases caused by exposure to asbestos are listed in the current German list of occupational diseases under number 4104. Parallel to a multicenter study to evaluate whether a CT scan should be included in the examinations for occupational diseases according to the German surveillance guidelines, an additional ENT examination was evaluated. PATIENTS AND METHODS: One hundred workers with a mean exposure time to asbestos of 20.9 years were given a complete ENT examination in 4 consecutive years (1993-1996). Radiological signs for asbestosis were observed in 21 cases and 58 participants had pleural affections caused by asbestos. Significant nicotine abuse was reported by 15 persons: 61 participants were ex-smokers and 24 had never smoked. Regular alcohol consumption was reported by 90% (11% more than 80 g/day). RESULTS: As documented in the literature, we found a high prevalence of laryngitis, especially in smoking patients. One patient had early laryngeal cancer (T1). CONCLUSION: The integration of an ENT examination into the German surveillance guidelines for occupational diseases should be discussed for patients with a high exposure to asbestos.

[Basic principles and concepts of enteral nutrition of ENT patients]. / Grundlagen und Konzepte zur enteralen Ernährung von HNO-Patienten.

Patients suffering from head and neck cancer often show malnutrition even at the time of diagnosis. Therapeutic measures as surgery, radiation and antineoplastic chemotherapy additionally decrease the nutritional status. Therefore, an early supportive intervention is necessary in accordance to prognosis and quality of life. For many reasons, enteral nutrition has advantages to total parenteral nutrition. Percutaneous endoscopically guided gastrostomy (PEG) is the method of choice, for the application of enteral nutrition in most cases; special situations can be covered by using nasogastral feeding tubes, jejunostomy techniques, open surgical approach or radiologically guided gastrostomy. The industry provides a lot of different products suitable for nearly all patients. Furthermore, PEG facilitates the application of pharmacological agents, e.g. analgetics. However, the patient must be integrated in a network of professional care to ensure a safe nutrition therapy also in an outpatient setting.

[Expert-assessment of suitability for a driving license in otorhinolaryngology]. / Verkehrsmedizinische Begutachtung in der Hals-Nasen-Ohren-Heilkunde.

An absolute requirement for acquiring a driving license according to German law consists in the suitability for driving a motor vehicle. The "driving license decree" defines these requirements; in case of doubt the administrative authority may demand a medical certificate. According to law (enactment: 1.1.99) these medical certificates must be refunded by either appropriate medical specialists, company doctors or public health officers. The criterions for appraisal are set down in the guidelines for driving ability which are edited by the advisory board for traffic medicine; a new edition will be published soon. Concerning otorhinolaryngology hearing impairment and dizziness are the most relevant diseases. Bilateral deafness is no general exception for conferring a driving license for the classes A and B; for classes C and DE hearing loss, established from the pure tone audiogram must not exceed 60%; an exceptional case is a three year demonstration of reliability in class B. Permanent dizziness or vertigo attacks are in most cases incompatible with conferring driving licenses. The most important issue for medical appraisal is to determine the amount of compensation of the impaired sense organ. Therefore in cases of multiple disabilities more stringent criterions must be established.

[Evaluation of the "new" TNM classification of head and neck tumors in 3247 patients]. / Evaluierung der neuen TNM-Stadieneinteilung für Kopf-Hals-Tumoren anhand von 3247 Patienten.

UNLABELLED: The 5th edition of the TNM classification entails a number of changes concerning head and neck tumors. The division of stage IV tumors into three subcategories marks a significant expansion of the stage grouping procedure. METHODS: In a retrospective study the clinical course of 3247 patients with head and neck carcinomas were comparatively evaluated according to the 4th and 5th editions of the new TNM classification. In particular it was the aim of the study to test the prognostic relevance of the subdivision of stage IV especially in mucosal cancer. RESULTS: In classifying the primary tumor the most extensive changes were noted for supraglottic and salivary gland tumors. On the basis of the 4th edition of the TNM classification the following recurrence-free 5-year survival rates for 3033 cases of mucosal cancer were calculated: stage I 91,0%, stage II 78.6%, stage III 61.4%, stage IV 31.0%. The calculations based on the 5th edition yielded: stage I 91.0%, stage II 77.2%, stage III 61.2%, stage IVA 32.4%, stage IVB 25.3%, stage IVC 3.6%. CONCLUSIONS: The adequacy of the revised stage classification in establishing a prognostic hierarchy was confirmed. However, a significant prognostic distinction between N2- (stage IVA) and N3-metastasis (stage IVB) could not be found.