[The relevance of mirror examination in modern otorhinolaryngology]. / Relevansen af spejlundersøgelse i moderne otorhinolaryngologi.

INTRODUCTION: The aim of this study was to investigate whether the teaching of mirror examination of the larynx and rhinopharynx is still relevant and to estimate whether it is still a reliable examination. MATERIAL AND METHOD: Twenty-five patients underwent a mirror examination of the larynx and rhinopharynx by a young doctor, a young otorhinolaryngologist, and a senior otorhinolaryngologist. RESULTS: Not surprisingly the senior otorhinolaryngologist conducted the most adequate examinations. Forty-three percent of the laryngoscopies were adequate, that is all anatomic structures were seen. Forty-one per cent provided a reasonable survey, that is a few anatomic structures were not seen. This shows that 84% of the laryngoscopies could be used to give a reasonable examination of the larynx. Only 27% of the rhinoscopies were completely adequate, and as many as 49% were inadequate. DISCUSSION: Routine mirror examination of the larynx adequately provides a reliable diagnosis in most patients. But in some, it is not adequate, and here fibrolaryngoscopy is a good alternative and a more reliable examination. Mirror examination of the rhinopharynx is difficult, so if a disease of the rhinopharynx is suspected, the patient must be given a fibroscopy and biopsy under general anaesthesia.

[Vestibular schwannoma. A new interpretation of tumor growth]. / Vestibularisschwannomer. En ny fortolkning af vaekstresultater.

INTRODUCTION: The goal of the present paper was to investigate the growth of vestibular schwannoma (VS). MATERIAL AND METHOD: A series of 123 patients with 127 tumours were allocated to the wait and scan group in the period 1973 to 1999. The material was updated three times medio 1993, medio 1996 and medio 1999. Via the Danish national register, data on whether the included patients were alive or dead were collected medio 1999. Three sets of growth results were obtained. RESULTS: The results medio 1993 revealed: tumour growth in 94 tumours (74%), no growth in 23 tumors (18%) and negative growth in 10 tumors (8%). Medio 1996 the results changed to: tumour growth in 104 tumors (82%), no growth in 15 tumours (12%) and negative growth in eight tumours (6%). The growth figures changed again in medio 1999 to: tumour growth in 108 tumours (85%), no growth in 11 tumours (9%) and negative growth in eight tumours (6%). However, the results may also be interpreted in another way: 52 patients (42%) are alive, tumour growth did not demand any intervention, 23 patients (19%) died due to non-tumour related causes and 35 patients (28%) were previously treated and alive by the termination of the third observation period. CONCLUSION: It is concluded that tumour growth is time dependent, surgery at diagnosis is the ultimate solution, however the current study provides a number of arguments in favour of the wait and scan policy.

Preliminary results of a new delivery system for gentamicin to the inner ear in patients with Meniere's disease.

Intratympanic gentamicin therapy has gained some clinical popularity in the treatment of vertigo associated with Meniere's disease. This therapeutic modality offers some advantages over traditional surgical treatment. The vestibulotoxic effect of gentamicin is well documented, but there is no general agreement about the dose needed to control vertigo attacks without affecting hearing. In the current preliminary study 27 patients with Meniere's disease refractory to medical management were treated by small doses of gentamicin delivered via microcatheter in the round window niche and administered by an electronic micropump. The patients received a total dose of 0.24-90 mg. The effect on vestibular symptoms resulted in the cessation of vertigo in the 22 patients, control of drop attacks in 4 of 6, and release of aural pressure and fullness in 2 of 4. Significant hearing loss (anacusis) occurred in six patients, slightly related to the flow rate in the pump setting. Different explanations for the loss of hearing are presented. The new delivery system for gentamicin appears to be effective in controlling vertigo, but with an unacceptable negative effect on hearing. The effectiveness and the safety of this new delivery system must be investigated further in controlled studies. However, it opens up the possibility of future novel ways of treating inner ear diseases, such as sudden deafness and tinnitus, as well as for the protection, repair, and regeneration of inner ear sensory cell function in damage due to aging, noise, toxic substances, immune reactions, etc.

Vestibular schwannoma growth: the continuing controversy.

OBJECTIVE: To investigate the growth of vestibular schwannoma (VS) in a series of 123 patients with 127 tumors allocated to the "wait and scan" group in the period 1973-1999. STUDY DESIGN: Retrospective review of prospectively registered data on all patients with VSIE from the entire country who were allocated to the wait and scan group. METHOD: Clinical charts, audiometric data, and neuroradiological images were reviewed and tabulated for age, hearing level expressed as speech reception threshold (SRT) and speech discrimination score (SDS), maximum extra-canalicular tumor extension, and possible changes in tumor diameter. The material was updated three times (in June 1993, June 1996, and June 1999). Via the Danish national register, data on whether the included patients were alive or dead were collected in 1999. RESULTS: The tumor growth, growth rate, and growth patterns were calculated in three periods 1973 to 1993 (mean observation period, 3.4 y), 1973 to 1996 (mean observation period, 3.8 y), and from 1973 to 1999 (mean observation period, 4.2 y). By termination of the first period, 94 tumors (74%) exhibited measurable growth, 23 tumors (18%) no measurable growth, and 10 tumors (8%) revealed negative growth. By the end of the extended observation period, tumor growth was observed in 104 tumors (82%), no tumor growth in 15 tumors (12%), and negative growth in 8 tumors (6%). Subsequent to the third observation period, growth was observed in 108 tumors (85%), no growth in 11 tumors (9%) and negative growth in 8 tumors (6%). However, the results may also be interpreted in another way: 52 patients (42%) were alive at the time of writing, tumor growth did not demand any intervention, 23 patients (19%) died as a result of non-tumor-related causes, and 35 patients (28%) were previously treated and alive by the termination of the third observation period. CONCLUSION: Depending on the observation period, three sets of growth results were obtained. The long observation period, updating and re-updating the results, gave us the opportunity for a de novo interpretation of the results and the long-term consequences of the wait and scan policy. Combined with other factors, the achieved results should be considered when timing of surgery is to be decided.

[Surgical results of submandibular gland excision]. / Kirurgiske behandlingsresultater ved eksstirpation af glandula submandibularis.

INTRODUCTION: Extirpation of the submandibular gland is the standard treatment for benign disease in cases where conservative treatment fails. This study attempts a follow-up focusing on: the effectiveness of the treatment, the number of complications and the long-term complaints related to this surgical procedure. MATERIAL AND METHODS: This study included 110 patients who, due to benign disease, underwent submandibular gland excision at our hospital during 1989-1995. All the patients had their charts reviewed and were invited for a follow-up consultation, with an examination and an interview about complaints arising after the procedure. RESULTS: Average follow-up time was 7.2 years (range 3.3 to 9.4 years) and 72 patients (65.5%) reported back for follow-up. Sixty-eight of the examined patients (92%) reported relief from their preoperative symptoms. Forty-three patients (42%) had complications in connection with their surgery and fifteen patients (15%) needed a reoperation. The most frequent postoperative complaints were dryness of the mouth and reduced function of the marginal branch of the facial nerve. DISCUSSION: Most of the patients achieved relief of symptoms after surgery. There were a high number of complications, but most of these were of minor severity and temporary. The frequency of palsy in the submandibular branch decreased with time after operation while the frequency of oral dryness increased with time. Excision of the submandibular gland is an effective low-risk treatment for benign disease in the submandibular gland.

Incidence of vestibular schwannoma in Denmark, 1977-1995.

OBJECTIVE: To establish the incidence rate of vestibular schwannomas (VS) (acoustic neuromas) in Denmark. BACKGROUND: The worldwide incidence rates of VS vary from 1 to 20 cases per million population per year. METHODS: The nationwide and population-based age-specific, sex-specific, and calendar year-specific incidence rates of VS in Denmark between 1977 and 1995 are presented. Information on cases of VS was obtained from the Danish Cancer Registry and a clinical database situated at the University Hospital of Gentofte. A total of 795 cases were reported during the period of the study. RESULTS: The incidence rate increased from 5 cases per million population per year in 1977-1981 to 10 cases in 1992-1995; the increase was from 5 to 11 cases among women and 5 to 9 cases among men. The age-specific incidence rates show that VS is rarely diagnosed in persons under 30, but the incidence rate appears to increase among women after menopause. CONCLUSION: The overall incidence rate of VS increased linearly during the study period, probably owing to the introduction of more precise diagnostic procedures, increased awareness among physicians and patients of the symptoms of VS, improved registration of benign tumors in Denmark, and the use of data from two sources.

Vestibular schwannoma growth--long-term results.

The growth of vestibular schwannoma (VS) was investigated in a series of 123 patients with 127 tumours during 3 periods: 1973 to 1993 (mean observation period 3.4 years), 1973 to 1996 (mean observation period 3.8 years) and 1973 to 1999 (mean observation period 4.2 years). Three sets of growth results were obtained. At the end of the first period, 94 tumours (74%) exhibited measurable growth, 23 tumours (18%) no measurable growth and 10 tumours (8%) negative growth. Tumour growth was observed in 104 tumours (82%), no tumour growth in 15 tumours (12%) and negative growth in 8 tumours (6%) at the end of the extended observation period. Growth was observed in 108 tumours (85%), no growth in 11 tumours (9%) and negative growth in 8 tumours (6%) subsequent to the third observation period. However, the results can be interpreted in another way: 52 patients (42%) are alive, tumour growth required no intervention; 23 patients (19%) died due to non-tumour-related causes; and 35 patients (28%) were previously treated and alive by the end of the third observation period. Together with other factors, the results reported here should be considered when timing of surgery is to be decided.

Cystic vestibular schwannoma--clinical and experimental studies.

The cystic variant of vestibular schwannoma (VS) presents a therapeutic dilemma. Several studies have previously demonstrated that the surgical outcome in this tumour entity is less favourable than that of solid tumours of comparable size. The "wait and scan" policy has not been recommended for these tumours, as the cystic elements expand, causing displacement of the brainstem and compression of the 4th ventricle, resulting in hydrocephalus. The large tumour size at diagnosis and the cystic contents do not support the role of radiosurgery as a therapeutic option. We have previously published the surgical outcome of 23 cystic VS. The present study includes 44 patients (44 cystic tumours) in a series of 773 tumours (5.7%) who underwent surgery in the period 1976 to 1996. This paper presents the neuroradiological and histological features of the tumours, as well as the results of tumour specimen implantation and surgery in athymic nude mice. Therapeutic options are also discussed.

Intracanalicular vestibular schwannoma--therapeutic options.

The growth of purely intrameatal vestibular schwannoma (VS) was investigated in a series of 40 patients with 40 unilateral VS in the period 1973 to 1996 (mean 3.6 years). Twenty-seven tumours (67.5%) revealed growth and 13 tumours (32%) had no measurable growth. Four growth patterns were observed: (i) 15 tumours (37.5%) exhibited constant growth; (ii) 13 tumours (32.5%) had no measurable growth; (iii) 8 tumours (20%) revealed growth subsequent to a no-growth period; and (iv) 4 tumours (10%) manifested different growth patterns during the observation period. The mean diameter growth per year was 3.2 mm. The findings of the present study, especially those achieved in groups B (the non-growing tumours) and C (tumour growth subsequent to a silent period), question the reliability of the results achieved by radiosurgery, as no tumour growth may occur with no intervention.

Round window gentamicin mu-catheter--a new therapeutic tool in Ménière's disease.

The vestibulotoxic effect of gentamicin is well documented; however, there is no general agreement on the gentamicin dose needed to control vertigo attacks without affecting the hearing. In the current study, 14 patients with Ménière's disease refractory to medical treatment were treated by small doses of gentamicin delivered via a mu-catheter, placed into the round window niche. An electronic micropump delivered 10 microliters (100 micrograms)/h. The patients received a total dose of 4-14 mg. The effects on the vestibular symptoms were most encouraging, with cessation of vertigo in 13 of the 14 patients, control of Tumarkin attacks in 4 out of 6 cases and release of aural pressure and fullness in 2 out of 4 cases. According to the recommendations of the Committee on Hearing and Equilibrium, the patients in this material belonged to functional levels 5 and 6. At the last clinical follow-up, five patients were classified as level 1, eight patients as level 2 and one patient as level 3. A significant hearing loss was seen in one patient; however, this was most likely due to the natural development of the disease in this particular case. The results look promising, but must be investigated further in a placebo-controlled study.

Surgical outcome in malignant parotid tumours.

Of 494 parotid gland tumours treated in Copenhagen county (population 600,000 inhabitants) in the period 1986-95, 50 patients (34 males, 16 females) had tumours that were proven to be malignant, making an incidence of 0.62/100,000/year. The patients age ranged from 14 to 87 years, mean 64 years. According to the UICC classification system, 6 tumours (12%) were classified as stage I, 23 (46%) as stage II, 14 (28%) as stage III, and 7 (14%) as stage IV. The material included 41 primary parotid gland tumours, histologically the tumours were verified as mucoepidermoid carcinoma (n = 13), adenocarcinoma (n = 9), squamous cell carcinoma (n = 6), carcinoma ex pleomorph adenoma (n = 3), acinic cell carcinoma (n = 3), adenoid cystic carcinoma (n = 3) and other histological diagnoses (n = 4). Primary malignant lymphoma of the parotid gland was diagnosed in six tumours and the last three tumours were metastatic carcinoma. Four therapeutic modalities were applied: surgery only, surgery + radiation, surgery + chemotherapy, and surgery + chemotherapy + radiation. Surgical radicality was achieved in 76% and radicality was unrelated to tumour histology. Normal or nearly normal facial nerve function (HB1&2) was noted at last follow-up in 60%. Five-year crude survival for all patients was 68%. Survival was not dependent on N-classification. Patients in stage I had a better survival than did patients in stages II, III and IV. No significant difference was observed in 5-year crude survival or in the post-operative facial nerve function between the radically operated patients (n = 38) and patients with residual tumour (p = 0.27, Log-rank test), (p = 0.48, chi 2 test).

Effect of photodynamic therapy on a heterotransplanted human parotid tumor.

To evaluate the effect of photodynamic therapy on human parotid tumors we used tumor specimens obtained from parotid surgery on a consecutive group of patients. The tumors were transplanted into a subcutaneous pocket of nude mice. The original human tumors were pleomorphic adenoma (four), adenolymphoma (one), acinic cell carcinoma (one), sarcoma (one) and low-grade adenocarcinoma (one). The most aggressive growth was seen in the low-grade adenocarcinoma. We re-implanted this tumor on ten mice bilaterally, and treated the tumors with photodynamic therapy (PDT), resulting in a mean depth of tumor necrosis of 5.4 mm (1-10 mm). In three cases we found vital tumor cells in the periphery of the tumor after treatment, with several new blood vessels in the surrounding tissue, indicating a great potential for neo-angiogenesis in this tumor. In order to evaluate the possible nerve damage subsequent to the photodynamic therapy, the ischiadic nerve in 24 lower limbs of nude mice were investigated. In one case only the macroscopical and histological investigation revealed signs of nerve damage. The current study demonstrates that the nude mice implantation model is excellent to investigate growth in both malignant and benign parotid tumors, and to test new therapeutic modalities. Photodynamic therapy seems to have a possible role in the future management of the malignant lesions of the parotid gland, in cases where radical surgery for some reason is not achievable.

Cystic vestibular schwannoma: surgical outcome.

We investigated the proportion of the cystic form of vestibular schwannoma and assessed the results of surgery in this subtype of the condition. The definition of cystic vestibular schwannomas was based on the following criteria: per-operative identification of cystic components; occurrence of the hypodense/hypointense areas on computed tomography (CT) and/or magnetic resonance (MR); and histological verification of S-100 protein membrane-like structures. In a study of 773 Danish patients with vestibular schwannomas, 44 (5.7 per cent) displayed cystic components. The outcome of surgery on 44 cystic vestibular schwannoma (mean tumour size 39 mm) was evaluated and compared with that for 151 solid grant vestibular schwannoma (mean tumour size 49.8 mm). Per-operatively, we found a substantially higher adherence to different intracranial structures in the solid giant vestibular schwannoma compared with the cystic vestibular (95 per cent vs 70 per cent for brainstem, 91 per cent vs 59 per cent for trigeminal nerve, 85 per cent vs 45 per cent for cranial nerves X and XI, 67 per cent vs 32 per cent for dura). Nevertheless, the preservation of the facial nerve function was much better in patients with solid giant vestibular schwannoma compared with those with cystic vestibular schwannoma (House-Brackmann facial nerve dysfunction grade 6 (one year post-operative): 27 per cent vs 41 per cent, respectively p < 0.04). We conclude that the cystic components in vestibular schwannoma are associated with a less favourable surgical outcome, probably due to the rapid tumour growth and symptoms caused by compression of the posterior fossa structures.

[Treatment of malignant parotid tumors. Results from the county of Copenhagen]. / Behandling af maligne parotistumorer. Resultater fra københavns amt.

Out of 494 parotid gland tumours treated in Copenhagen county (population 600,000 inhabitants) in the period 1986 to 1995, 50 patients (tumours) were proven to be malignant, making an incidence of 0.62/100,000 per year. Age ranged between 14 and 87, mean 64 years. According to the UICC classification system, six tumours (12%) were classified as stage I, 23 (46%) as stage II, 14 (28%) as stage III and 7 (14%) in stage IV. Four therapeutic modalities were applied: surgery only, surgery + radiation, surgery + chemotherapy and surgery + chemotherapy + radiation. Surgical radicality was achieved in 76% and radicality was unrelated to tumour histology. Normal or nearly normal facial nerve function (HB1&2) was noted at last follow up in 60%. Five year crude survival for all patients were 68%. Survival was not depends on N-classification. Patients in stage I had a better survival compared to patients in stage II, III and IV. No statistically significant difference in five year crude survival between the radically operated patients (n = 38) and patients with residual tumour (p = 0.27, log rank-test), (p = 0.48 chi2-test was found.

[Diagnosis and growth evaluation of vestibular schwannomas by SPECT combined with TL-201 thallium]. / Vestibularis-schwannomers diagnostik og vaekst bedømt ved SPECT kombineret med TL-201 Thallium.

The value of SPECT scanning in diagnosis and growth potential of vestibular schwannoma (VS) was investigated in a series of 29 patients. SPECT demonstrated all tumours > 0.8 cm3, but had limitations as a diagnostic modality of small intracanalicular tumours, when compared to gadolinium DTPA enhanced MR. SPECT was found to be valuable in determining VS growth potential as it reflects tumour vascularity, which is essential for tumour growth. A high radioactive tracer uptake in the tumour corresponded to high tumour vascularity, indicating a high growth rate and vice versa. It seems that we now have an in vivo functional radiological modality capable of providing data on VS vascularity and determination of growth potential in the individual tumour.

[Intraoral cancer in the county of Copenhagen]. / Intraoral cancer i Københavns Amt.

A retrospective study of patients treated for intra-oral squamous cell carcinoma in Copenhagen county is reported. The material included 156 patients, 66 females and 90 males. Age at diagnosis varied between 35 and 95 years with a mean of 65 years. Mean age of females/males was 70/62 years. Twelve therapeutic modalities were performed; surgery, radiotherapy, chemotherapy and different combinations of these. Five year disease specific survival related to tumours' T-classification was 84% for T1, 35% for T2, 20% for T3 and 27% for T4. A statistically significant relation between the tumours' T-classification and the disease specific survival was noted (p < 0.00001). Five year disease specific survival related to N-classification was 62% for N0, 30% for N1, 25% for N2 and 0% for N3. Crude five year survival was 37% overall, 61% for patients in stage I, 32% for patients in stage II, 16% for patients in stage III and 17% for patients in stage IV. The results are similar to those achieved in other centres. Since no significant improvement has been noted in patient survival during the last five to six decades and since the therapeutic morbidity has not always been acceptable to the patients, other therapeutic principles, such as the so called minimal invasive therapy should be considered in future treatment of intra-oral cancer.

Incidence of vestibular schwannomas.

OBJECTIVE: To determine the incidence of vestibular schwannoma (VS) in Denmark in a period of 191/2 years. STUDY DESIGN: Retrospective review of prospective registered data on all patients with VS operated on by the translabyrinthine, lateral suboccipital, or middle cranial fossa approach, as well as patients who were allocated to the "wait-and-scan" group. METHODS: Charts were reviewed and tabulated for age, extrameatal tumor extension, and date of diagnosis. The available data were divided into three periods: June 1976 to June 1983, July 1983 to June 1990, and July 1990 to December 1995. RESULTS: The number of newly diagnosed tumors in the first period was 278, corresponding to an incidence of 7.8 tumors/million population per year; in the second period 337, corresponding to an incidence of 9.4 tumors/million population per year; and in the third period 355, corresponding to an incidence of 12.4 tumors/million population per year. A significant increase in incidence of the newly diagnosed intracanalicular tumors in the second and third periods was observed. CONCLUSION: The increase in incidence of VS can probably be explained by the awareness among otolaryngologists of the diagnosis of VS and better access to computed tomography and magnetic resonance imaging scans. The observed increase in the diagnosis of the small and intrameatal tumor creates a clinical dilemma, whether to operate on tumors in this early stage or to allocate patients to the wait-and-scan group. This problem will still be relevant in the upcoming years, since the incidence of intrameatal and small VS is expected to increase.

[Results of bat ear surgery over a period of ten years]. / Resultater af stritøreoperationer i en tiårig periode.

A material of 286 patients or 545 ears submitted to operation for protruding ears operated by Stenströms and Nordzells surgical procedure over a period of ten years were reviewed retrospectively. One hundred and sixty-three patients were clinically investigated and interviewed. The mean observation time was eight years. Satisfactory results were obtained in 94% of the patients subjectively. Objectively there was a good result in 74% of the cases. Relatively few complications and reoperations occurred. However 20% of the patients interviewed had postoperative pain more than one year after the operation. The results of the operations are reviewed and discussed. There was no significant difference between the results of the surgical procedure a.m. Stenström and a.m. Nordzell.

[Oral ranula. A follow-up study]. / Mundbundsranula. En efterundersøgelse.

Ranula is a cystic swelling of the floor of the mouth, which is usually unilateral and relatively uncommon. The cyst arises from the sublingual salivary gland. We reviewed 14 patients operated in the period 1976-April 1998. There was no recurrence after marsupialization and after extirpation of the sublingual gland. Fourteen percent of the patients had recurrence after extirpation of the cyst. At the follow-up time (average 8.1 years) 18.2% had complications. We suggest that marsupialization/extirpation of the cyst should be primary treatment. In case of recurrence the sublingual gland should be extirpated.

Management of intrameatal vestibular schwannoma.

The growth of purely intrameatal vestibular schwannoma (VS) was investigated, in the period 1973-96 in a series of 40 patients with 40 unilateral VS. In the present study, the material was analysed and updated. By the end of the observation period (mean 3.6 years), 27 tumours (67.5%) revealed growth and 13 tumours (32%) had no measurable growth. Four growth patterns were observed: (A) 15 tumours (37.5%) exhibited constant growth; (B) 13 tumours (32.5%) had no measurable growth; (C) 8 tumours (20%) revealed growth subsequent to a no-growth period; and (D) 4 tumours (10%) showed different growth patterns during the observation period. The annual diameter growth rate ranged between 00 mm/year and 6.5 mm/year and the mean diameter growth per year was 3.2 mm. The findings of the present study, especially those for group B (the non-growing tumours) and C (tumour growth subsequent to a silent period) bring into question the reliability of the results achieved by radiosurgery, as without any intervention it may be that no tumour growth occurs.