[False Medical Treatment Investigation in Otorhinolaryngology by the MDK in Lower Saxony and Bremen]. / Behandlungsfehlerbegutachtung in der HNO-Heilkunde bei den MDK Niedersachsen und im Lande Bremen.

Objective: In a retrospective study the cases of possibly false medical treatment investigated by the Health Advisory Boards (MDK) in Lower Saxony and Bremen, Germany, in the years from 2012 to 2015 were analyzed. Material and Methods: All relevant data - especially diagnoses and procedures - were recorded in accordance to a standardized data entry form and were evaluated. In addition, relevant case studies are presented. Results: Altogether 206 cases of possibly false medical treatment were recorded for the investigated period. Among them there were 24 cases (12%), in which a false medical treatment was detected. The relevant case studies showed on the one hand, that relevant false medical treatment does occur in the field of ENT-surgery and on the other hand that it is sometimes very difficult do get the right decision even on a high-skilled background. Conclusions: In the field of Otorhinolaryngology there is a constant number of cases for examination in possibly false medical treatment, although the number of detection of false medical treatment is rather lower than in other disciplines. Analysis of possible false medical treatment cases produces the chance of preventing false medical treatment in future.

Inflammatory diseases of the salivary glands in infants and adolescents.

OBJECTIVE: To determine retrospectively the localization, etiology and treatment of inflammatory diseases of the salivary glands in infants and children and to evaluate treatment outcome. PATIENTS AND METHODS: Forty-five patients were treated in our institution in the period 1966-2000. The patients' records were evaluated and the results and side-effects of therapy were documented by a controlled follow-up study. RESULTS: Twenty-five of our patients were females (55.6%) and 20 males (44.4%). Inflammatory disorders figured most prominently in the group of patients between 12 and 16 years (n=14). Inflammation of the submandibular glands was the most common disease with 53.3% (n=24). The most frequent underlying cause in this subgroup of acute and chronic sialadenitis was sialolithiasis of the submandibular gland (40%). All patients were symptom-free in the long-term follow-up and all were symptom-free after surgical intervention. CONCLUSIONS: The present study shows that diseases of the salivary glands are rare among infants and children. Acute and chronic sialadenitis not responding to conservative treatment requires an appropriate surgical approach.

Successful management of drooling with botulinum toxin A in neurologically disabled children.

OBJECTIVES: The present study investigates the effect of topical injections of botulinum toxin A into the cephalic salivary glands of children with chronic hypersalivation due to neurodegenerative diseases. METHODS: Five children with hypersalivation due to severe neurological diseases received, under ultrasound guidance, a total of 50-65 units of botulinum toxin A (Botox) into the parotid and submandibular glands on both sides. All injections were tolerated without local anaesthesia. Before and 1, 2, 4, 8 and 12 weeks after toxin injection, salivary flow rates and the concentrations of total protein, alpha-amylase, acid phosphatase, kallikrein, and immunoglobulin A were measured in the secretions; simultaneously, the patients were clinically examined with regard to severity of symptoms, and their salivary glands were subjected to ultrasound study. RESULTS: A distinct improvement of symptoms within the first 2 weeks following toxin administration were reported by the parents. Sialometry revealed considerably reduced flow rates but sialochemistry showed an increase of amylase activity. Ultrasound examination did not reveal any changes of the salivary parenchyma, and side-effects were absent. CONCLUSION: Treatment of drooling by topical injection of botulinum toxin A into the salivary glands is a reliable and also side-effect-free therapeutic option for children with neurological disorders. All children involved in our study experienced a distinct improvement of their quality of life.

[Blocking secretion of exocrine glands in the head-neck area by administration of botulinum toxin A. Therapy of a rare disease picture]. / Sekretionshemmung exokriner Drüsen des Kopf-Hals-Bereiches durch Applikation von Botulinum Toxin A. Therapie seltener Krankheitsbilder.

BACKGROUND: Hypersecretion disorders of the exocrine glands of the head and neck area are a therapeutic problem in the field of otorhinolaryngology. In the present study, we demonstrate the effectiveness of local injections of botulinum toxin A to block secretions of exocrine glands of the head and neck area. PATIENTS AND METHODS: Four patients suffering from hypersecretion disorders received local injections of botulinum toxin A. Two patients suffered from disorders of the salivary glands: one presented an idiopathic hypersialorrhea and another a salivary fistula after parotidectomy. A third patient suffered from epiphora and a further patient presented severe hyperhidrosis on the pilose head region. In a retrospective clinical study, the outcome of therapy was evaluated by clinical examination and chemical parameters. RESULTS: Clear blocking of secretion in the treated glands could be demonstrated in all four cases. Possible side effects of the treatment could not be observed. CONCLUSIONS: The present study was able to demonstrate a clear blocking of secretion of the exocrine glands of the head and neck region through botulinum toxin A, offering an improvement in therapy especially for the innovative indication of blocking the salivary glands of the head.

The effect of local injection of botulinum toxin A on the parotid gland of the rat: an immunohistochemical and morphometric study.

PURPOSE: In this investigation, the effect of a local injection of botulinum toxin A on the concentration of acetylcholinesterase in the parotid gland of the rat was examined. MATERIALS AND METHODS: After local injection into the parotid glands of female Wistar rats, the treated glands were excised, and immunohistochemical staining for acetylcholinesterase was performed. To discover possible changes in cell morphology after local application of botulinum toxin A, morphometric measurements also were performed on the excised parotid glands. RESULTS: In contrast to the untreated, physiologic saline-injected, glands, there was a decrease in the concentration of acetylcholinesterase in the glands treated with botulinum toxin. No persistent changes in the number of acinar cells could be observed. CONCLUSIONS: Because the cholinergic pathway of the autonomic nervous system has great importance in the secretion of fluid from the salivary glands, blocking this pathway and local application of botulinum toxin offers a possible therapeutic option for the treatment of hypersalivation in various otolaryngologic and neurologic diseases.

Gustatory sweating: clinical implications and etiologic aspects.

PURPOSE: It was the aim of this study to provide detailed general information on the clinical picture of different kinds of gustatory sweating, including reevaluation of a series of patients who underwent parotidectomy, removal of the submandibular gland, or neck dissection. PATIENTS AND METHODS: This study summarizes the statements of 548 patients questioned about the occurrence of gustatory sweating after parotidectomy (n = 296), extirpation of the submandibular gland (n = 79), and neck dissection (n = 173). RESULTS: After parotidectomy, 45% of the patients had noticed gustatory sweating. In most of them (70%), the symptoms began within 6 months after surgery. Gustatory sweating developed in only one patient with submandibular extirpation (1.5%), and not at all after neck dissection. Most patients (52%) reported that the symptoms occurred independent of the kind of food ingested. These results show that the "masticatory component" is an important trigger for Frey's syndrome. Application of Minor's test localized gustatory sweating mainly in the region of previous parotid lobe removal, but also in other areas deriving their sensory supply from the auriculotemporal, greater auricular, and lesser occipital nerves. The size of the area affected by the sweating was similar after lateral and total parotidectomy. When evaluating clinical symptoms, subjective assessment by the patients seemed to play a major role. After submandibular extirpation and neck dissection, some patients reported gustatory sweating that was not verified by Minor's test. CONCLUSION: There is general agreement that the cause of gustatory sweating is sympathetic or parasympathetic innervation of previously denervated sweat glands, initiated by gustatory triggers. The location of the "erroneous innervation" depends on the type of lesion. In cases after parotidectomy, misdirected parasympathetic regeneration is the model integrating all known factors into a rational concept. For didactic and systematic-pragmatic reasons, a clinically oriented classification of gustatory sweating (types I to III) seems to be useful.

Immunohistochemical and morphometric investigations of the influence of botulinum toxin on the submandibular gland of the rat.

Immunohistochemical methods were used to study the effects of botulinum toxin A on the concentration of acetylcholinesterase in the submandibular gland of the rat. The toxin was injected into the glands of healthy adult female Wistar rats and immunohistochemistry performed on the excised organs. Morphometric measurements were also carried out to study changes of cell morphology after local applications of botulinum toxin A. Compared with untreated glands or glands injected with saline there was a decrease of acetylcholinesterase in the glands treated with botulinum toxin. As the cholinergic pathway of the autonomic nervous systems plays an important role in eliciting secretion from the salivary glands, inhibition of secretion by local application of botulinum toxin could be considered a therapeutic option for the treatment of various diseases affecting salivary gland function.

Clinical evaluation and surgical management of congenital preauricular fistulas.

PURPOSE: The retrospective investigation evaluated the clinical data on patients with a preauricular fistula with respect to demographic factors, symptoms, preoperative diagnosis, and surgical therapy. Follow-up studies served to critically assess the outcome of the operations. PATIENTS AND METHODS: The records of 62 patients were studied. Patients were divided into two groups: those operated on for the first time for a preauricular fistula and those operated on for a recurrence. Controlled follow-up was performed by means of a standardized questionnaire filled out by both the patients' physicians and the patients themselves. RESULTS: The mean age of patients operated on for the first time was 16 years, and that of patients operated on for a recurrence was 22 years. Although the overall rate of recurrence was 21%, it differed widely between groups (14% in first operations and 42% in patients operated on for the first time for a recurrence). These figures are within the lower range of the recurrence rates previously reported. Serious side effects, such as persistent damage to the facial nerve, were not observed. CONCLUSIONS: Operative management of a preauricular fistula is a treatment with few side effects that should be offered to each patient with such a malformation. Because the first operation is decisive for the further course of the condition, surgery should be performed under optimum conditions to avoid recurrence.

Extraglandular Warthin's tumours: clinical evaluation and long-term follow-up.

Nine patients with extraglandular cystadenolymphoma (Warthin's tumour) were treated between 1965 and 1995 at the Department of Otorhinolaryngology, University of Göttingen. This number corresponds to 2.7% of all Warthin's tumours treated at our clinic so far. Although this rare tumour is well documented by case reports, a controlled follow-up study has not yet been published to the best of our knowledge. The retrospective investigation presented here gives the patients' clinical data and documents therapeutic success. Our results show the complete absence of recurrences after surgical excision of extraglandular cystadenolymphomas.

Surgical management of nonneoplastic diseases of the submandibular gland. A follow-up study.

A total of 233 patients with nonneoplastic diseases of the submandibular gland were treated between 1966 and 1992 at the otorhinolaryngology department of the University of Göttingen. Of them, 212 patients (91%) suffered from sialadenitis with or without sialolithiasis, and 21 (9%) suffered from other diseases. The first part of the present study analyzes the clinical data with regard to history, symptoms, and therapy. It was found that in most cases (77%) extirpation of the affected gland had been the standard operation. In the second part, the surgical procedures applied are critically assessed. Extirpation of the submandibular gland proved to be an effective therapy in all patients. Side-effects were rare. The management of chronic sialadenitis caused by calculi should include extirpation of the submandibular gland. In case of calculi not causing inflammatory disease, lithotripsy should be considered.

Surgical management of benign tumors of the submandibular gland: a follow-up study.

PURPOSE: This retrospective study evaluated data pertaining to history, symptoms, diagnosis, and mode of therapy of patients treated for benign tumors of the submandibular gland. PATIENTS AND METHODS: The records of 38 patients were reviewed. The patients were divided into three groups: pleomorphic adenoma (first operation), pleomorphic adenoma (second operation for recurrence), and other tumors. Follow-up was done by questionnaires sent to the patient and referring doctor. RESULTS: The vast majority of patients treated (92%) had had either a first or second operation for pleomorphic adenoma. Follow-up revealed that recurrence did not develop in the group of patients with primary surgery. However, one patient undergoing surgery for recurrent pleomorphic adenoma developed two recurrences. Two patients suffered from slight weakness of the lower lip. CONCLUSION: Tumor recurrence was found only in the cases of second operation after previous surgery for pleomorphic adenoma. Therefore, the first operation should extirpate the entire gland to minimize the risk of recurrence.

[Exulcerating cystadenolymphoma of the parotid gland. A case report]. / Exulzerierendes Zystadenolymphom der Glandula parotis. Ein Fallbericht.

A recurrent adenolymphoma of the left parotid gland occurring in a 79-year-old woman is reported having caused an extensive ulceration of the epidermis, clinically suggestive of a malignant tumour. The ulcerative tumour process cannot be explained by a particular pattern of growth or a malignant transformation of the adenolymphoma. It is assumed that residual tumour cells of the initially incompletely removed adenolymphoma spread via a long-standing postoperative fistula to the epidermis leading to the uncommon ulceration.

Values and value--a vision for the Australian health care system.

The Australian health care system is at a crossroads. Status quo is not a sustainable option for the future. Rising consumption, spiralling costs, the decline of private health insurance and a public sector 'bursting at the seams' threaten our traditional values of a universal, affordable, accessible, equitable, high-quality system. As a result, we believe that major reform of the health care system is both necessary and inevitable in order to ensure that the values of the system are maintained and to extract maximum value from limited health resources. In this article we lay out our vision for the Australian health care system. It is a vision characterised by transformational change--shifting of risk from patients and taxpayers to providers, downsizing of acute care capacity, integration of services across the system, rationalisation of State and Federal responsibilities and a 'shakeout' of providers and insurers resulting from intensified, but bounded, competition. We believe that the direction for health care players needs to be clarified so that, as a country, we can continue to have a best practice model of health care delivery. We present this vision as a 'stake in the ground' to set parameters around which this debate can emerge. It may be provocative and challenging, but it is our vision into the future.

Botulinum toxin treatment in patients with hemifacial spasm.

Hemifacial spasm is nearly always a unilateral disease of the facial musculature and is characterized by involuntary tonic or clonic cramps that considerably reduce the affected patient's quality of life. In the past, a number of different conservative and operative therapeutic procedures have been applied for the treatment of hemifacial spasm. In many cases these attempts failed to control the disease permanently or resulted in unwanted, sometimes strong, side effects. We report our own experiences with botulinum therapy in 29 patients with hemifacial spasm (78 therapeutic sessions). In our patients the mean duration of an effect after treatment with botulinum toxin was 18.2 weeks. Side effects were rare. Our results since 1990 at the University of Göttingen demonstrate that subcutaneous application of toxin from Clostridium botulinum to involved facial muscles represents a reliable method for successful treatment of hemifacial spasm.