[Trivial injury to the sole of the foot]. / Banale Verletzung an der Fußsohle.

A 67-year-old male patient noticed a foreign body sensation following a trivial trauma to the sole of the left foot approximately 4 months before presentation. The existing skin alteration had been self-treated with pumice stone and an unidentifiable wart tincture. The examination revealed an approximately 2 cm in diameter macula on the left heel with a zonal construction. The periphery was formed by a polycyclic dark brown ring which enclosed a reddish skin colored macula with several minute erosions. Dermatoscopy revealed an unspecific pattern with polymorphic vessels in the center. The peripheral ring showed radially running streaks as well as a parallel track-like pattern in one region. Histology revealed this to be an acral melanoma. A melanoma should always be included in the differential diagnostic considerations of atypical acral lesions. A biopsy should always be carried by unclear clinical and light microscopical findings out to enable a final diagnosis.

[Strategies for quality assessment of emergency helicopter rescue systems. The Graz model]. / Strategien zur Optimierung notärztlicher Kompetenz in der Flugrettung. Das Modell Graz.

PURPOSE: Preclinical emergency medical treatment necessitates a comprehensive interdisciplinary knowledge by the emergency physician as well as a high level of manual dexterity. The quality of treatment therefore depends on the level of education and continuous training in emergency medical techniques. Based on an evaluation of the frequency of life-saving interventions by a physician-staffed rescue helicopter system, strategies for in-hospital training of relevant skills are suggested. MATERIAL AND METHODS: At the outset, 10 important areas of treatment (e.g. intubation, chest tube etc.) and their frequency in emergency medical services were defined as the standard to be attained by emergency physicians within 1 year. The selection of the areas of treatment was based to some extent on international recommendations. The actual frequencies of the prehospital interventions were compared to the required minimum numbers by retrospective analysis of the helicopter rescue database (NACA-X). RESULTS: During the observation period of 1 year, 20 emergency physicians responded to 956 prehospital emergency calls. A life-threatening condition requiring an on-site intervention occurred in only 521 (54.5%) patients, so that the majority of physicians did not perform the required minimum number of interventions. In order to maintain their level of skill, the emergency physicians were required to undertake additional training at the local university hospital. CONCLUSION: The frequency of on-site life-saving interventions in emergency medicine is insufficient to fulfill the quota necessary to maintain adequate training of emergency physicians. Only a link-up program at a hospital for primary care can ensure an adequate training level.

[Diffuse hyperplastic oncocytosis of the parotid gland]. / Die diffuse Onkozytose der Glandula Parotidea.

BACKGROUND: Oncocytes are epithelial cells characterized by an granular, eosinophilic cytoplasma, and a centrally situated, pycnotic nucleus. These cells were first observed by Hamperl 1931 in the salivary glands. Ultrastructural studies have shown that the cytoplasma of these cells is filled with numerous large and bizarre mitochondria. The exact biological significance of oncocytes is unknown - Becker, Donath and Seifert suggest an intracellular metabolic disturbance associated with mitochondriopathy, caused by an age dependent metabolic defect. Oncocytes are not specific for the salivary glands; they are also found in the thyroid gland, parathyroid gland, liver, pancreas, esophagus and the kidney. Solitary oncocytes appear most often as incidental findings in aging salivary tissue, they are present in persons older than 70 years up to 80 %. The diffuse hyperplastic oncocytosis of the parotid gland represents an extremely rare, non-tumorous alteration of the parotid gland. Caused by an extensive metaplasia of acinic and ductal cells nearly the entire gland consists of oncocytes. Clinically it is characterized by swelling of the parotid gland. Oncocytic adenomatous hyperplasia is a different disease. It represents a multifocal oncocytic proliferation of the duct system. In contrast to diffuse oncocytosis remnants of the original salivary tissue with acini and fatty tissue are usually present between the oncocytic nodules. Typical oncocytomas may possibly develop from such oncocytic proliferation by a tendency to confluent growth. METHODS: Cases of diffuse hyperplastic oncocytosis of the parotid gland were identified by literature review. RESULTS: Worldwide diffuse hyperplastic oncocytosis of the parotid gland has been observed in 8 cases (Fig. ) as of today. PATIENT: We report and discuss the case of a 78-year-old male, who was refered to our hospital because of a painless mass of the left parotid gland. MRI showed a tumorous lesion with a diameter of about 5 cm. Lateral parotidectomy was performed. Histology revealed an extremely rare case of diffuse hyperplastic oncocytosis. There has been no recurrence of tumor after 2 years. CONCLUSIONS: Diffuse hyperplastic oncocytosis of the parotid gland is an extremely rare benign disorder, complete excision of the tumor-like lesion is curative. In literature there has been no report of recurrence, malignant transformation or metastasizing illness.

The function of tensor veli palatini muscles in patients with aural symptoms and temporomandibular disorder. An EMG study.

This preliminary study investigated Myrhaug's neuromuscular hypothesis by means of audiological and electromyographic assessment. After a clinical examination of the TMJ system, the activity of the tensor veli palatini muscles in the state of rest and during swallowing was investigated in 16 patients with the help of an EMG recording, and the tube-opening function was evaluated endoscopically. Results showed that 6.25% of the patients suffered from mild joint-dysfunction (group I), 81.25% from a moderate dysfunction (group II), and 12.5% from severe dysfunction (group III). Although five patients suffered from tinnitus and 11 from fullness in the ear, both the audio- and tympanogram performed on 15 patients displayed normal recordings. Only one patient suffered from moderate sensorineural hearing loss. In the EMG recording, 11 of the 16 subjects displayed normal EMG patterns in state of rest and during swallowing contraction. In two cases, abnormal EMG recordings were obtained due to incorrect insertion of the EMG needle. The study's results indicate that spasm in the masticatory muscles of TMJ patients neither seems to cause reflex spasm of the tensor palatini muscles nor to effect significant alterations in Eustachian tube function.

Immunogenicity of a combined hepatitis A and B vaccine in healthy young adults.

Combining several vaccines in a single formulation can change the potency of the vaccine antigens. Previous studies suggested a higher immunogenicity of a new combined hepatitis A and B vaccine compared with the monovalent hepatitis B vaccine. We investigated the immune response to hepatitis B surface antigen 1 month after the third vaccine dose in 282 healthy adults who had received either a monovalent hepatitis B vaccine (n=148) or the combined hepatitis A/B vaccine (n=134). A slight trend towards higher geometric mean titres of anti HBs was found at this point in time in the group immunised with the combined vaccine, especially in the few vaccinees with preexisting antibodies against hepatitis A virus. However none of these differences was statistically significant, arguing against an advantage of the combined vaccine regarding hepatitis B immunisation.

Expression of CD34-antigen in nasopharyngeal angiofibromas.

Formalin-fixed, paraffin-embedded and frozen tissues of 24 patients with primary nasopharyngeal angiofibroma, of whom seven had recurrences, were studied immunohistochemically for the expression of CD34 antigen using two different antibodies (HPCA-1 and QBEND 10). In all cases, there was an exclusive staining of endothelial cells, while pericytes, smooth muscle cells and stromal fibroblasts were not reactive. The staining intensity, however, was more pronounced in small tumor vessels of capillary- and sinusoidal-type than in larger vessels, which were usually characterized by an irregular smooth muscle coat. This differential staining indicates an increased proliferative potential of the endothelium of the small vessel component of nasopharyngeal angiofibroma (neoangiogenesis) and an inhibitory influence of vascular smooth muscle cells on endothelial cell growth. Moreover, the positive immunoreaction of all endothelial cells for CD34 is indicative of the absence of lymphatic vessels, which confirms previous ultrastructural observations. No differences in the staining pattern were observed between primary versus recurrent tumors, formalin fixed, paraffin embedded versus snap-frozen acetone fixed material, or between both CD34 antibodies. Our findings indicate that nasopharyngeal angiofibroma is a vasoproliferative malformation.

[Isolated unilateral otitis with facial nerve paralysis as initial symptom of Wegener granulomatosis. An unusual clinical course]. / Isolierte einseitige Otitis mit Fazialisparese als Erstsymptom bei Wegener-Granulomatose. Ein ungewöhnlicher klinischer Verlauf.

BACKGROUND: Wegener's granulomatosis is an immunepathogenic disease of unknown origin. The histopathological picture shows granulomatous inflammation with epitheloid cells, granulomas, and general vasculitis. The diagnosis of Wegener's granulomatosis is made on the basis of the clinical picture, serum cANCA, and histologic examination of biopsies. PATIENT: We present the case of a 57-year-old white male patient who was admitted to our ENT Hospital with a six weeks' history of otalgia and incomplete ipsilateral facial palsy since the day before admission. The patient had clinical features of acute otitis media without signs of mastoiditis. Despite a ten days' course of intravenous antibiotic treatment, the intensity of facial palsy progressed and the general condition of the patient worsened. A mastoidectomy and decompression of the facial nerve were performed, demonstrating sclerosis of the mastoid cells. Three weeks after release from the hospital, the patient was admitted again with recurrent fever, cephalea, loss of weight, and arthritic pain. There were no signs of recurrent otitis media or mastoiditis, and sigmoid sinus thrombosis was ruled out. Even under aggressive, intravenous antibiotic treatment the general physical condition continued to worsen; septic temperatures and signs of beginning renal failure occurred. The patient was transferred to the ICU with the diagnosis of sepsis of unknown origin. There bloodtests were positive for cANCA, which is highly specific for Wegener's granulomatosis. Under therapy with cyclophosphamide and i.v. corticosteroid, the patient recovered with 14 days. CONCLUSION: The lack of symptoms in the upper respiratory tract in our patient was unusual, indicating that in patients with recurrent otitis media, facial palsy, mastoiditis, or external otitis Wegener's granulomatosis should be ruled out as differential diagnosis.

Immunohistochemical and electron microscopical characterization of stromal cells in nasopharyngeal angiofibromas.

Twenty-eight cases of nasopharyngeal angiofibroma were studied immunohistochemically for cytoskeletal phenotyping of stromal cells. Electron microscopy was also used to study the ultrastructure of five of the tumors. All typical stromal cells showed intensive immunostaining for vimentin, but were negative for smooth muscle actin and desmin. Ultrastructurally, most of these cells appeared to be exclusively fibroblasts. However, in some areas stromal cells were seen that morphologically resembled myofibroblasts by their shapes and arrangement, and were characterized by the coexpression of vimentin and smooth muscle actin. Electron microscopy confirmed their myofibroblastic nature. The present study showed that the typical stromal cells in nasopharyngeal angiofibromas were fibroblasts and not myofibroblasts. In these tumors myofibroblasts occurred only focally, in connection with fibrotic areas and exclusively as a vimentin+/actin+cytoskeletal phenotype. This indicates that myofibroblasts are not primary stromal tumor cells in nasopharyngeal angiofibromas, but occur due to regressive changes.

Paragangliomas of the carotid bifurcation: oncological aspects of vascular surgery.

The present study reviews in concise form the past 12 years of our clinical experience with paragangliomas of the carotid body. Every aspect of the anatomical, histological and biological and biological behaviour of paragangliomas of the carotid body has been recorded in order to be able to define better surgical management and the clinical prognosis. In addition to the conventional histological methods of investigation we also applied immunohistochemistry and made use of electron microscopy. Eighteen tumours of the carotid body in 12 female and four male patients with a mean age of 54 years (34 to 70 years) were treated surgically. Angiography of the aortic arch and supra-aortic branches was undertaken diagnostically in every case. In three patients computer tomography and magnetic resonance imaging demonstrated spreading of the tumour up to the base of the skull and pre-operative embolization of the arteries supplying the tumour was performed to decrease tumour vascularity. In four cases (22%) resection of the internal carotid artery and its reconstruction by a saphenous vein graft was required in order to achieve the therapeutic aim of a complete extirpation of tumourous tissue and preserving the vascular system of the internal carotid artery. In three cases (16%) there was histological evidence of a metastasizing process to the local lymph nodes of the neck and, due to this criterion of malignancy, 50-60 Gy of radiation was applied to the site of the tumour after surgery. Four patients experienced a transient neurological deficit in the supply area of the hypoglossal and the recurrent nerves. In one case, the vagus nerve could not be retained. In an average follow-up of 102 months we recorded one case of local recurrence 13 months after the initial resection and radiation treatment applied to a malignant paraganglioma. All the other patients were doing well without evidence of recurrent disease.

Ultrafast computed tomography and three-dimensional image processing of CT sialography in patients with parotid masses poorly defined by magnetic resonance imaging.

The purpose of this study was to determine the efficacy of ultrafast computed tomography (UF CT) in patients with parotid masses poorly defined by magnetic resonance imaging (MRI) and to evaluate the diagnostic potential of three-dimensional (3-D) UF CT sialography when compared with conventional CT sialograms. Thirteen patients with clinical suspicion of a parotid mass, in whom MRI was degraded by motion, underwent UF CT of the parotid region. Two radiologists independently assessed the CT and MR with respect to tumor localization, intraglandular tumor location, tumor margin characteristics, and infiltration of surrounding tissue. In 9 patients, CT sialography was performed using 3-D image processing. Anatomical details and pathologic findings were assessed by three readers using a numerical grad and compared with the findings derived from conventional CT sialography. Histopathologic specimens were obtained in all cases and correlated with the radiographic findings in a consensus manner following the blinded interpretations. UF CT and (suboptimal) MRI provided the same diagnostic information for the evaluation of tumor localization, and intraglandular location. UF CT was superior to MRI in the detection of tumor infiltration, and definition of tumor margins in 2 cases (15%), resulting in a substantial difference in treatment. Three-dimensional CT sialography offered significant improvement in demonstration of anatomic detail (2.5 +/- 0.2 vs 1.5 +/- 0.1, respectively) and pathologic findings (2.6 +/- 0.1 vs 1.3 +/- 0.2, respectively) when compared with conventional CT sialography. UF CT is a viable alternative in uncooperative patients with parotid masses. UF CT 3-D sialography has the potential to allow more precise pre-surgical planning and contributes to the diagnosis and therapy planning of parotid masses.

Homoeopathic versus placebo therapy of children with warts on the hands: a randomized, double-blind clinical trial.

BACKGROUND: Despite the wide practical application of homoeopathy, scientific proof of its effectiveness and mechanisms is still lacking, and sound, placebo-controlled studies are scarce. OBJECTIVE: The purpose of our study was to evaluate the efficacy of homoeopathy in a prospective, double-blind randomized trial. METHODS: 60 children aged 6-12 years with common warts on the back of the hands were treated either with an individually selected homoeopathic preparation (n = 30) of at least a 1:1,012 dilution or with pure placebo in the form of saccharose globuli (n = 30) under double-blind conditions. The area occupied by warts was measured by computerized planimetry before and after 8 weeks of treatment. Reduction of the warty area by at least 50% was considered a response. RESULTS: There were a total of 16 responders: 9 of 30 patients in the homoeopathic therapy group and 7 of 30 patients in the placebo group (chi 2 = 0.34, p = 0.56). Total cure of warts occurred in 5 patients in the treated group and in 1 patient in the placebo group (chi 2 = 1.46, p = 0.22). CONCLUSION: There was no apparent difference between the effects of homoeopathic therapy and placebo in children with common warts under the conditions of this study.

[An interdisciplinary therapy concept in treatment of paragangliomas of the skull base--demonstrated with a case]. / Ein interdisziplinäres Therapiekonzept in der Behandlung von Paragangliomen der Schädelbasis--demonstriert anhand einer Kasuistik.

Surgical resection of paragangliomas in the cervical region is complicated due to the tumour vascularity and is associated with the risk of major intraoperative blood loss. Preoperative angiographic embolization of the tumour supplying arteries by intravascular injection of gelfoam and implantation of microcoils was performed to decrease tumour vascularity. We report the case of a 78 years old female patient suffering from a carotid body tumour. Computed tomography demonstrated spreading of the tumour from the carotid bifurcation up to the base of the skull. Primary surgical resection was aborted because of the bleeding tendency of the tumour. Tumour embolization was required in order to achieve the therapeutic aim of a complete extirpation of tumourous tissue by preserving the vascular system of the internal carotid artery. The reported case is completed by a review of literature.

[Personal experiences with endoscopic endonasal surgical technique in therapy of sinusitis in childhood]. / Unsere Erfahrungen mit der endoskopisch-endonasalen Operationstechnik bei der Therapie der Sinusitis im Kindesalter.

At the ENT-Department of the University-Hospital of Graz the endoscopic-endonasal surgical approach according to Messerklinger and Stammberger has been used for years in the treatment of inflammatory diseases of the paranasal sinuses in the paediatric population. Especially in children this technique concern the growing facial part of the skull and tooth buds. It is very safe and effective, since it is adapted to the physiology and pathophysiology of the respiratory mucosa. In a retrospective study 145 patients who were operated on within 11 years at the ENT-Department of the University-Hospital of Graz, were investigated to evaluate this method. Information about the age of patients, preoperative symptoms, predisposing factors, indications for surgery, the operative procedure itself and its extension such as intraoperative problems and complications were included in this study. By a subjective patient evaluation the stress placed on the patient by the procedure and the therapeutic success were investigated. From the good results of this study we infer the justification for the primary use of this surgical method in inflammatory diseases of the paranasal sinuses in children.

[Haller's cells: morphologic evaluation and clinico-surgical relevance]. / Die Haller'schen Zellen: Morphologische Evaluierung und klinisch-chirurgische Bedeutung.

Ethmoidal cells that have developed into the floor of the orbit or into the roof of the maxillary sinus, respectively, are known as Haller's cells. 528 patients, in whom functional endoscopic sinus surgery was performed, were explored regarding the presence of Haller's cells. 43 patients presented with Haller's cells at least on one side (8.14%). CT scans of these patients were evaluated morphometrically measuring the dimensions of the Haller's cells as well as of the maxillary sinus. Further anatomical variations of the paranasal sinuses (concha bullosa, supraorbital cell, agger nasi cell) and the keros type of the ethmoid sinus roof were seen. A highly significant difference could be demonstrated between the incidence of Haller's cells in men (4.9%) and women (11.9%). For the first time it was possible to demonstrate a frequency distribution between Haller's cells deriving from the anterior ethmoidal cells (88%) and those originating from the posterior ethmoidal cells (12%). In 56% Haller's cells were opacified on CT-scan showing a mucosal swelling respectively a retention of secretion during endoscopic surgery.

[Prevention of vascular complications in endonasal paranasal sinus surgery. Part II: Pre- and intraoperative imaging]. / Vermeidung vaskulärer Komplikationen bei der endonasalen Nasennebenhöhlenchirurgie. Teil II: Prä- und intraoperative Bildgebung.

Computer-assisted surgery (CAS) is a new intraoperative localization system that is based on digital image generation devices. The system has been used in 189 cases of paranasal sinus procedures, employing computed tomography (CT) image data. Highly accurate imaging and localization of bony structures can be achieved in this way, although definition of vascular structures is limited by representation attributes of vessels in CT. Algorithms have now been developed for the use of magnetic resonance angiography (MRA) data with the system. CAS was used in six cases of endonasal surgery. Imaging helped substantially in all cases, but its application was limited by incomplete reflection of small vessels. In one case, intraoperative findings showed MRA-inherent inaccuracies. These might be avoided using correction programs and phantom selection (shimming) procedures in the future. Additionally, matching of different imaging modalities should improve intraoperative applications of CAS.

[Functional structure of the human vocal cord]. / Zur funktionellen Struktur der menschlichen Stimmlippe.

19 laryngeal specimens (11 male, 8 female) were cut in horizontal serial sections, parallel to the free edge of the vocal cord. After staining, the structures of the glottis were measured microscopically and statistical analysis of the sex-related differences performed. The results show that the glottis can be divided not only into the well-known anterior and posterior glottis, but into five histological and functional distinctive portions. Within the anterior glottis, these parts are the freely vibrating midportion of the vocal cord, which is connected to the stiff laryngeal frame via an anterior and posterior transition zone. Within the posterior glottis there are two parts: the vocal process of the arytenoid cartilage (which is, according to Hirano, also the cartilage portion of the vocal cord) and the lateral wall of the posterior glottis. Statistical analysis of the data revealed significant sex differences, not only in the absolute measures but also on comparing the relative dimensions in respect of the total glottic length. The posterior glottis accounts for 37% of the total glottic length in men and for 42% in women and is therefore longer than generally accepted. We found statistically significant sex-related differences in the length of the posterior glottis, which is absolutely longer in men but relatively longer in women. The reason for this is the difference in the length of the midportion of the vocal cord. This zone is twice as long in men (8.5 mm) than in women (4.6 mm) and accounts for 37% of the total glottic length in men compared to 29% in women. As this portion is the most vibrating part of the vocal cord this could be an explanation for the unsolved phenomenon why the fundamental frequencies are 1:2 between men and women while all dimensions of the larynx are 1.5:1. The vibrating midportion of the vocal cord is connected to the stiff laryngeal framework by highly differentiated transition zones: the nodulus elasticus anterior and posterior. The lamina propria of the midportion shows a three-layered structure, orientated parallel to the free edge of the vocal cord. In the transition zones the deep layer of the lamina propria consists of interwoven bundles of collagen and elastic fibres, thus having the function of a "cushion ball" (Hirano). A functionally important portion is the vocal process of the arytenoid cartilage. The complex movements of the vocal process during abduction and adduction of the vocal cords produce a severe mechanical strain on the mucous membrane covering this part of the glottis.

[Prevention of vascular complications in endonasal paranasal sinus surgery. I: Anatomic principles and surgical significance]. / Vermeidung vaskulärer Komplikationen bei der endonasalen Nasennebenhöhlenchirurgie. Teil I: Anatomische Grundlagen und chirurgische Bedeutung.

Anatomic and histologic investigations were performed in 59 cadaver half-heads in order to demonstrate areas of hazard at the posterior skull base during endoscopic surgery and determine morphologic features of surgical relevance. In 78% of the heads the internal carotid artery bulged into the sphenoid sinus from laterally directly behind and beyond the tuberculum for the optic nerve ("anterior bulging"). In 25% of all cases the carotid artery also bulged into the sphenoid sinus from behind ("posterior bulging"). This bulging could amount to as much as 7 mm. Additionally, the thickness of the bony wall at the point of the largest prominence could be very thin (0.1 mm), with 12% of all cases showing bony dehiscences. The width of the posterior ethmoid cells and pneumatization of the paranasal sinuses at this point differed widely, ranging from 8-24 mm. Classification of the carotid loop into five different types demonstrated that the bulgings of the internal carotid artery were larger in more curved types of the artery ("omega" and "U" types) and were smaller in less curved types ("Arkus" and "V" types).

Nasopharyngeal angiofibroma: an immunohistochemical study of 32 cases.

Thirty-two cases of nasopharyngeal angiofibroma, including 2 recurrences, all of which had been excised from males between 7 and 25 years, were subjected to systematic immunohistochemical study. Most of the tumour vessels, which lacked elastic laminae, were characterized by vascular walls of irregular thickness and variable muscle content. In places endothelial cells were only separated from the stroma by a single attenuated layer of contractile cells, whereas elsewhere the same vessel walls showed pad-like thickenings of their muscle coat. All cells of the vessel walls showed immunoreactivity for vimentin and smooth muscle actin, whereas desmin-positive cells were present only in small numbers in some vessels, generally those with thicker muscle coats. The stromal cells were decorated by vimentin antibodies only; however, in some more fibrotic hyaline areas the stromal cells displayed also reactivity for smooth muscle actin. In most cases S-100 protein-staining disclosed many nerves, and this accentuated their parital distortion by tumour tissue. Our findings provide an extended insight to the morphology of angiofibromas at this site, particularly highlighting the irregularity of their vascular walls, which, taken together with the lack of elastic laminae and elastic stromal fibres, can be held responsible for the typical pronounced tendency for haemorrhage in these lesions.

Danger areas of the posterior rhinobasis. An endoscopic and anatomical-surgical study.

In 52 cadaveric half-heads, an endoscopic sphenoethmoidectomy was performed. Then, an anatomical preparation with registration of specific data like bulging of the optic canal, thickness of the bony wall covering the optic nerve and the internal carotid artery was achieved, followed by histological sections in specially selected cases. Thus the two key areas of major surgical hazard in the posterior rhinobasis could be clearly demonstrated: the immediate topographic relation of the optic canal and the internal carotid artery to the lateral wall of the sphenoid sinus and the cells of the posterior ethmoid respectively. Onodi cells of varying degrees were found in 42% of all cases. The thickness of bony wall over the maximum bulging of the optic canal averaged 0.28 mm. Bony dehiscences could be demonstrated in 12% of the cases. The technique of data acquisition, the anatomical and histological findings as well as their clinical and surgical relevance are discussed.