Malleostapedotomy: the Marburg experience.

BACKGROUND: The surgical procedure for patients with otosclerosis routinely is incus stapedotomy. In case of otosclerosis with incus necrosis or a bony fixation of the malleus and incus, malleostapedotomy is performed. PATIENTS AND METHODS: Between May 2002 and September 2003, malleostapedotomy was performed in 6 out of 34 patients with otosclerosis. In 2 primary cases, a middle ear dysplasia was found. The malleus was fixed in 2 further primary cases. Two revision surgeries were performed with incus necrosis present. A titanium piston was used, which was fixed at the malleus handle and introduced into an opening of the footplate. RESULTS: The preoperative air-bone gap was reduced from 36 dB(A) to 13 dB(A) after surgery for an average checkup time of 3 months. The length of the prostheses varied from 6.3 to 7.5 mm. No patient showed a hearing loss or vertigo after surgery. CONCLUSION: Malleostapedotomy is the technique of choice in case of an additional pathology of the ossicular chain in patients with otosclerosis. Larger numbers of patients and long-term investigations need to compare the results of malleostapedotomy with those of a conventional incus stapedotomy.

[State of the art of classification, diagnostics and therapy for cervicofacial hemangiomas and vascular malformations]. / "State of the Art" zur Klassifikation, Diagnostik und Therapie von zervikofazialen Hämangiomen und vaskulären Malformationen.

The successful treatment of vascular anomalies depends on profound knowledge of the biologic behavior of vascular lesions and their correct classification. On the base of the clinical course Mulliken and Glowacki developed a biologic classification that was accepted as official classification by the ISSVA (International Society for the Study of Vascular Anomalies). Based on an extended literature research, this manuscript will give an overview of different internationally accepted treatment concepts. Even if a wait-and-see strategy can be recommended in many cases of uneventful hemangiomas in infants the proliferative growth of such lesions requires an adequate treatment indication. Vascular malformations that persist lifelong require treatment in the majority of the cases, especially when clinical symptoms occur. Based on individual parameters such as the diameter, location or growth behavior, different therapeutic options as cryotherapy, corticosteroids, laser therapy, sclerotherapy, surgical intervention and/or embolisation can be performed successfully. None of those treatment concepts, however, represents the only treatment method of choice.

Teaching and assessment in otolaryngology and neurology: Does the timing of clinical courses matter?

Little is known about the effectiveness of clinical courses as a learning environment. To accurately assess performance in these courses, equal conditions for all candidates are required. We investigated the influence of the proximity of the course to the students test taking, the students' learning styles, and their self-motivation for learning in relation to performance success. One hundred and eleven students were randomized into eight groups, each attending a 2 week course in otolaryngology with a high proportion of patient-related teaching, and a 2 week long course in neurology with a low level of patient-related teaching. All students took multiple-choice end-of-term exams to assess their knowledge in both subjects. There was a different time interval between the course participation and the test taking for each of the groups. Performance success was correlated with the different groups, as well as with the type of learning style (LIST questionnaire) and with motivation for learning (study interest questionnaire). Explorative rank variance analysis showed a significant correlation between students' performance on the written exam and the time interval between completion of the neurology course and test-taking, with the shortest interval corresponding to highest scores (P = 0.002). There was no such effect on the success rate in otolaryngology (P = 0.28). Study motivation was not the major component for performance success, but a strong correlation between the use of strategic and deep learning styles and success in the exam was observed (R = 0.62; P < 0.001). The duration of time between a clinical course with little practical teaching and the students' taking of the exam plays a significant role on performance success; this effect does not occur in a course with a high proportion of practical patient-related teaching. More studies on clinical courses are needed to establish how students can be given adequate opportunities to develop necessary skills for patient care and for objective success on assessment. With such further information, the effectiveness of clinical courses as a learning experience might be enhanced.

Early supraglottic cancer: how extensive must surgical resection be, if used alone?

OBJECTIVES: Two centre based evaluations of oncologic results of endoscopic resection of supraglottic cancer without post-operative irradiation. PATIENTS AND METHODS: Twenty-six patients with clinical T1 (n=5) or T2 (n=21) primary squamous cell carcinomas of the supraglottic larynx and with N0 (n=24) or N1 (n=2) neck disease were treated by endoscopic supraglottic laryngectomy coupled with neck dissection(s). Endoscopic resection was standardized whereas neck dissections (NDs) varied from classical modified radical ND to selective ND of levels I to IV. RESULTS: Pathologically, three T2 patients were upstaged to T3, four N0 patients to N1 and one N2 patient down-staged to N1. Within an average of 42 months, there were no local failures and only one regional failure. CONCLUSIONS: Endoscopic resection of T1 and T2 supraglottic cancer without post-operative irradiation achieved good oncological results. No patients with lateralized primary cancers were found to have contralateral cancer on pathological evaluation from bilateral dissections.

Meta-analysis of the prognostic significance of perinodal spread in head and neck squamous cell carcinomas (HNSCC) patients.

To assess the risk factor of capsular rupture for individual prognosis and potential therapeutic decision making, the present meta-analysis elaborated the prognostic significance of perinodal spread in a large group of patients suffering from head and neck squamous cell carcinomas (HNSCC). A review of the published literature was conducted, and fixed and random effects models were applied for estimation of the summarised odds ratio and 95% confidence intervals, including a test for homogeneity of the odds ratios. Study methodology allowed the enrollment of only nine studies of 115 published papers. Excluded studies lacked regarding primary tumour location, number and location of lymph node metastases, values on five-year survival, or adequate follow-up data. A summarised odds ratio of 2.7 leads to the conclusion that perinodal spread negatively impacts the five-year survival. The lower confidence limit of more than 2 also supports the concept that perinodal spread significantly reduces (doubled risk) the five-year-survival. These results support the conclusion that perinodal spread is a significant adverse risk factor for survival in patients with HNSCC.

Influence of matrix metalloproteinase 9 (MMP-9) on the metastatic behavior of oropharyngeal cancer.

BACKGROUND: The role of the single matrix metalloproteinases (MMPs) in the metastatic process of squamous cell carcinomas (SCC) is still obscure. MATERIALS AND METHODS: The MMP-9 expression was described immunohistochemically in 105 patients (40-79 years of age, mean: 57.84 years; 84 male, 21 female) suffering from orophatyngeal cancer (22x TI, 31x T2, 24x T3, 28x T4) with different neck stages (41x N0, 6x N1, 54x N2, 4x N3 neck). RESULTS: A significant correlation between MMP-9 expression and T stage (p < 0.05), N stage (r = 0.55, p < 0.01) and UICC stage (r = 0.55, p < 0.01) was revealed. Most remarkable was the high MMP-9 expression with simultaneously high UICC stages. CONCLUSION: The results give further indication that MMP-9 plays a role in the metastatic behavior of oropharyngeal SCC. It will be a project for the near future to create a standardized evaluation score of immuno-histological stainings to allow valid comparison of the results and published data.

Bipolar radiofrequency induced thermotherapeutic volumetric reduction of VX2 metastases in an animal model.

BACKGROUND: Radiofrequency-induced thermotherapy has shown promising results in the palliative treatment of various tumor entities. The purpose of this study was to investigate the effectiveness of bipolar radiofrequency volumetric tissue reduction (VTR) on lymph node (LN) metastases in the VX2 SCC model. MATERIALS AND METHODS: Six male New Zealand white rabbits, with palpable metastatic disease within the parotid lymph nodes, were treated using the Celon-ProSurge probe, needle length 10 mm, diameter of 2.3 mm. The animals were sacrificed on the 4th, 8th, 11th, 14th, 18th and 22nd postoperative days respectively. RESULTS AND CONCLUSION: Bipolar radiofrequency VTR could prevent progression of local metastatic disease in one-third of the animals compared to the control group of untreated VX2 carcinoma rabbits. These results encourage further studies, directed at whether this treatment modality could play a role in the palliative therapy of metastatic LN. Future studies should concentrate on the refinement of the treatment parameters and optimization of the treatment duration.

RT-PCR expression profiling of matrix metalloproteinases and their specific inhibitors in cell lines and fresh biopsies of squamous cell carcinomas of the head and neck.

The expressions of MMP2, -7, -9, -13 and TIMP1, -2, -3 were examined in biopsies and cell lines of head and neck squamous cell carcinomas (HNSCC) to determine the association between the expression profile and TNM-staging of the primary. The expressions of MMP2, -7, -9, -13 and TIMP1, -2, -3 were analyzed in 30 HNSCC biopsies, 7 HNSCC cell lines and 1 keratinocyte cell line using RT-PCR. Negative correlation was determined between N-status and MMP13-RNA expression [Kendall-tau-b -0.404 (p = 0.016), Spearman-rho -0.448 (p = 0.014)], histological grading [Kendall-tau-b -0.291 (p = 0.049), Spearman-rho -0,333 (p = 0.048)], and MMP7 and TIMP2 expression [Kendall-tau-b -0.318 (p = 0.045); Spearman-rho -0.353 (p = 0.045)]. Positive correlation was determined between M-status and MMP9-RNA expression [Kendall-tau-b 0.341 (p = 0.025), Spearman-rho 0.377 (p = 0.024)] and MMP13 and TIMP2 expression [Kendall-tau-b 0.727 (p = 0.037), Spearman-rho 0.850 (p = 0.016)]. The results point to a role of the tested MMPs and TIMPs in the metastatic spread of HNSCC.

Intraoperative lymphatic mapping in cases of midline squamous cell carcinoma.

OBJECTIVE: To analyze the value of intraoperative lymphatic mapping in cases of midline primary head and neck squamous cell carcinoma (HNSCC) in clinically staged N0 necks. MATERIAL AND METHODS: Eleven patients with HNSCC of the epiglottis (2 T1, 6 T2, 3 T3), all of whom were staged with a neck status of N0 using sonography and CT, underwent intraoperative peritumoral (99m)Tc-nanocoll injection (4 sites; 45 MBq), radiolabeled detection and analysis of up to 3 hot sentinel nodes (SNs) during elective neck dissection. RESULTS: Gamma probe use revealed bi- and unilateral intranodal tracer uptake in 6/11 and 5/11 patients, respectively. In 2/6 patients with bilateral intranodal tracer uptake an SN with an isolated metastasis was found at one neck site while the other four patients were tumor-free in the SNs. Of the five patients with unilateral intranodal tracer uptake, three had radiolabeled SNs containing isolated metastases whereas two had no cancer detected, giving a total occult cancer rate of 45% (5/11). No cancer was found in non-labeled nodes. CONCLUSIONS: Intraoperative lymphatic mapping correctly identified the stage of metastatic disease. Unilateral tracer uptake represented the pathway of occult metastatic spread in 3/5 patients and the disease-free neck status of both neck sites in 2/5 patients. No patient had occult bilateral cancer. Future investigations should be done to determine whether intraoperative lymphoscintigraphy can guide the indication for unilateral only or bilateral neck dissection in these patients.

Management of N0 neck in head and neck cancer: current controversies.

Squamous cell carcinomas of the upper aerodigestive tract are characterized by a high frequency of lymphogenic metastatic spread. The neck should be included in the treatment concept because almost 25% of all patients develop occult lymph node metastases. The only exception are early carcinomas of the lower lip and the vocal cords. Since currently for high risk patients no prognostic markers or other factors for occult metastatic spread are available, treatment strategies have to include the exact knowledge of direction and extent of regional lymphatic drainage. Based on this prerequisite, concepts for selective cervical lymph node dissection in case of the clinical N0 situation were developed which may also be used for an individually optimized radiotherapy. Intensity modulated radiotherapy (IMRT) bears a high potential for an optimized irradiation in case of potential occult metastatic spread of carcinomas of the upper aerodigestive tract. Without compromising local control rates IMRT allows a considerable reduction of permanent xerostomia by sparing at least one major salivary gland. The significant scientific purpose for the N0 neck, however, will remain the identification of high-risk patients, e.g. by means of tissue and/or serum-related markers, which carry a high risk of local and distant metastases.

Endoscopic sentinel lymphadenectomy as a new diagnostic approach in the N0 neck.

Sentinel lymphadenectomy was developed to reduce the extent of surgical interventions in cancer patients. The sentinel node (SN) concept was first established for melanoma and breast cancer; within some years, it also became increasingly popular for head and neck cancer. As soon as the required sensitivity of the method proves to be feasible in the daily clinical routine, the discussion about the best surgical approach to single or multiple SN(s) will arise. Different objectives may here compete with each other. The incision should render the best exposure of the operation site and should be expandable in case further lymph node regions have to be dissected. Finally, a good functional as well as a good cosmetic result is desirable. Endoscopic lymph node excisions were performed in patients suffering from squamous cell carcinoma of the upper aerodigestive tract located in different sites (1x uvula, 2x epiglottis, 1x glottis). In preoperatively performed ultrasonic imaging (B-mode-ultrasonography), N0 necks were assessed. In contrast to previously reported endoscopic techniques in humans, the presented method requires no insufflation of carbon dioxide or external retraction of the skin. Following laser surgical resection of the primary tumor, the SN and further lymph node(s) with accumulation of tracer substance were identified and resected endoscopically via an incision that was afterwards extended to a normal neck dissection incision. Reports of histopathologic examination of the sentinel node(s) were compared to the respective neck dissection specimens. The presented method may help to reduce the degree of invasiveness frequently attributed to sentinel lymphadenectomy once the method has been established for head and neck cancer.

Intravenous chemotherapy with cisplatin for regional lymph node metastases of auricular VX2 carcinoma.

INTRODUCTION: The VX2 carcinoma is well established as a useful model for studies on treatment of primary tumors of various locations including the rabbit's auricle; however, limited experience exists on the treatment modalities of lymph node (LN) metastases. In this investigation we studied the frequency and extent of lymphogenic metastatic spread of auricular VX2-carcinomas and their response to systemic chemotherapy. MATERIALS AND METHODS: Induction of a right-sided auricular VX2-carcinoma in 17 healthy New Zealand white rabbits was followed by ablation of the right auricle and intravenous application of 1 mg/kg KG CDDP (cisdiamminedichloroplatinum (II)) dissolved in 2 ml NaCl via the left-sided auricular vein in 10 rabbits (group 1), while 7 rabbits (group 2) remained untreated. After a 24-day follow-up period, animals of both groups were sacrificed and the regional draining LN as well as the lungs were isolated and examined histopathologically. RESULTS: Group 1. Following intravenous cisplatin therapy (ICT), 6/10 animals showed no vital tumor cells within LN metastases of the first draining LN station, while 4/10 animals had necrotic LN metastases limited to the parotideal LN. Group 2. All 7 animals showed necrotic LN metastases of the first and second draining LN station as well as pulmonary metastases. CONCLUSION: The auricular VX2-carcinoma, characterized by frequent lymphogenic metastatic spread and response of LN metastases to ICT, offers an excellent animal model for further studies on the optimised treatment of lymphogenic metastatic spread in HNSCC.

Extent of surgical intervention in case of N0 neck in head and neck cancer patients: an analysis of data collection of 39 hospitals.

In the discussion on the treatment of the clinical N0 neck in head and neck cancer, the sentinel lymphonodectomy is gaining more and more in significance. Prior to a multicentre study on the value of sentinel lymphonodectomy, it seemed to be desirable to collect data on the current practice of neck dissection in German ENT departments. First a standardised questionnaire was sent to 50 hospitals in Germany. It contained questions on the respective therapeutic concepts (uni- or bilateral modified radical neck dissection versus selective neck dissection, wait-and-see policy) in histologically proven squamous cell carcinoma (G2) and defined localisation of the primary tumour (T1-T2 carcinoma of the oral cavity, the oropharynx and hypopharynx as well as larynx). Summing up the evaluation of 39 anonymously answered questionnaires, it can be stated that no uniform therapeutic concept for the treatment of the cervical lymph nodes in carcinomas of the upper aerodigestive tract based on the stage of lymphatic metastatic disease exists. It seems to be essential to elaborate such a concept in order to be able to compete in the international context. Likewise, a widespread uniform therapeutic strategy would be the basic prerequisite for the initiation and realisation of multicentric therapy studies.

The auricular VX2 carcinoma--an animal model for sentinel node concept.

BACKGROUND: Considering the increasing clinical significance of the sentinel node (SN) concept, the applicability of the auricular VX2 carcinoma as an animal model for simulation of the SN concept was evaluated. MATERIALS AND METHODS: By means of blue dye and immunofluorescence-marked colloids, the lymphatic drainage of the auricle was described in 8 New Zealand white (NZW) rabbits. In 28 NZW rabbits, the extent of metastatic spread of auricular VX2 carcinomas after 8, 18, 21, 28 and 32 days of tumor growth was examined. RESULTS: Lymphogenic metastatic spread was limited to the parotideal lymph node functioning as SN for 21 days. The disintegration of the physiologic integrity of the SN leads to metastatic spread in the area of the secondary lymph node station after 28 days of tumor growth with successive hematogenic spreading. CONCLUSION: The auricular VX2 carcinoma in NZW rabbits is an appropriate animal model for simulation of the lymphogenic metastatic spread and the SN concept in HNSCC.

Peritonsillar abscess--critical analysis of abscess tonsillectomy.

The risk of secondary haemorrhage following abscess tonsillectomy is reported in the literature with differing rates. A retro- and prospective analysis of complication rates following abscess tonsillectomy was conducted in 142 patients (54 females, 88 males; mean age: 35 years). In 22% of patients, a secondary haemorrhage occurred. In half of these (11% of total), the haemorrhage had to be treated surgically. Secondary haemorrhage occurred most commonly on the 6th and 8th postoperative days. Reports in the literature are not in unison about the risk of secondary haemorrhage following abscess tonsillectomy and therefore allow no final judgement about an objective risk of this complication. This report strengthens the results of the 'Comparative Audit Service' analysis from 1997, which did show a high risk of secondary haemorrhage following tonsillectomy, as well as following abscess tonsillectomy.

Expression of MMP-2, -9 and -13 in cell lines and fresh biopsies of squamous cell carcinomas of the upper aerodigestive tract.

BACKGROUND: The expression patterns of the matrix metalloproteinases (MMP) 2, 9 and 13 have been examined in biopsies and cell lines of squamous cell carcinomas (SCC) of the upper aerodigestive tract to determine the association between MMP expression and the aggressiveness of the tumor. MATERIALS AND METHODS: The expression of MMP-2, -9 and -13 was analyzed by immuno-hybridization in 12 keratinocyte cell lines, 13 SCC cell lines and in 63 biopsies from SCCs of the upper aerodigestive tract. RESULTS: In biopsies a correlation was detected between T-status and the MMP expression [MMP-2 (p < 0.05), MMP-9 (p < 0.01), MMP-13 (p < 0.01)], between N-status and MMP expression [MMP-2 (p < 0.05), MMP-9 (p < 0.01)] and between UICC stage and MMP-9 expression (p < 0.01). CONCLUSION: The MMP-2, MMP-9 and MMP-13 expressions correlate strongly with pathological parameters. The determination of these tumor-biological parameters could help to identify high risk patients with increased frequency of metastatic spread.

Reduction of LOX- and LOXL2-mRNA expression in head and neck squamous cell carcinomas.

BACKGROUND: Besides other molecular functions, the lysyl oxidase gene (LOX) has been assumed and shown to have a tumor suppressive function in vitro and in vivo. The cancer-related functions of both LOX and LOXL2 have not yet been investigated in squamous cell carcinoma of the head and neck (HNSCC). MATERIALS AND METHODS: We examined the mRNA levels of LOX and LOXL2 in ten malignantly transformed cell lines and sixteen malignant tissue samples of different graded and staged HNSCC by RT-PCR. RESULTS: The LOX-mRNA level in both cell lines and tissues of HNSCC was markedly reduced as opposed to benign keratinocyte cell lines and mucosal tissue samples of the upper aerodigestive tract. Similar results were shown for LOXL2-mRNA levels in cell lines, whereas no reduction of LOXL2-mRNA levels was found in the malignantly transformed tissues. CONCLUSION: These findings support the presumption that LOX is involved in tumor suppressive processes and also of LOXL2 playing a role in malignant transformation.

Atypical mycobacterial tuberculosis--a diagnostic and therapeutic dilemma? Case reports and review of the literature.

In immunocompetent preschool children cervical lymphadenitis is a common clinical presentation of atypical mycobacteria. Its rapid diagnosis and treatment is still a challenge, because accurate diagnostic procedures for atypical mycobacteria are still not yet available in routine practice. Two children suffered from craniojugular (16 months old girl) and infraauricular (2.5 years old boy) located neck masses which showed resistance to the medical treatment. In the first case an abscess splitting took place initially, followed by an anti-tubercular drug treatment and necessary surgical reintervention. In the second case surgical removal of all involved lymph nodes, infiltrated surrounding soft tissue and involved skin areas were followed by medical treatment. In both cases presumed infection with mycobacterium tuberculosis was not confirmed, but atypical mycobacteria could be isolated both. In the first case atypical mycobacterium could be specified as mycobacterium avium complex and in the second case as mycobacterium malmoense. Both bacilli showed sensitivity towards medical treatment with clarithromycin, whereby in one case only the surgical reintervention led to a complete removal of clinical symptomatic. In cases of presumed tuberculous neck lymph node infections differential diagnosis of an atypical mycobacterial lymphadenitis should always be supposed, because medical and surgical treatment differ fundamentally.

Macrophage colony-stimulating factor as a tumor marker for squamous cell carcinoma of the head and neck.

It has been demonstrated that in patients with epithelial ovarian cancer and malignant germ cell tumors of the ovary, macrophage colony-stimulating factor (M-CSF) is significantly elevated in the serum compared to healthy individuals. Therefore, M-CSF has been suggested as a tumor marker in these malignancies. In the present study, the tumor marker potential of the serum M-CSF concentration in patients with squamous cell carcinomas of the head and neck (SCCHN) was investigated. The serum M-CSF concentration was determined by a quantitative sandwich enzyme immunoassay in 59 patients suffering from SCCHN and 59 healthy controls. A significant difference in the mean serum concentration of M-CSF between the patients with SCCHN and the control group was found (p = 0.002). The M-CSF serum concentration correlated neither with the stage of disease nor with histopathological grading, and no correlation with serum C-reactive protein was found. The serum M-CSF concentration could be of interest as a tumor marker in SCCHN.