[Laryngeal lead shot injury: therapy and follow-up]. / Laryngeale Schrotschussverletzung : Therapie und Verlauf.

Laryngeal shot injuries are rare. The case of a 65-year-old man who suffered from an injury with lead pellets is reported. After exploration with removal of the pellet from the lateral cricoarytenoid muscle, an immobility of the vocal fold developed, accompanied by impaired vocal function. Despite persisting immobility of the vocal fold, after 12 weeks voice compensation was achieved by voice therapy.

[Morphological and functional changes in nasal mucosa after nCPAP therapy]. / Morphologische und funktionelle Veränderungen der Nasenschleimhaut nach nCPAP-Therapie.

BACKGROUND AND OBJECTIVE: The treatment success of nCPAP therapy (nasal continuous positive airway pressure) depends partly on the relief of symptoms and partly on long-term patient acceptance and the related avoidance of complications. Nasal complaints constitute the most frequently reported side effects and, together with problems of mask application, are among the primary factors causing an nCPAP-therapy to be prematurely discontinued. PATIENTS/METHODS: To assess the morphological changes of the nasal mucosa during nCPAP-therapy, we excised specimens of nasal mucosa tissue in twelve patients with obstructive sleep apnea syndrome (OSAS) both before and 3-10 months after establishing nCPAP-mask acceptance. The specimens were examined by electron microscopy. RESULTS: In all these patients, acceptance of the CPAP mask marked the initial part of therapy. In addition, mucociliary clearance was assessed by the saccharin test before and after therapy. In all patients, the nasal epithelium underwent fundamental changes upon CPAP therapy, which became manifest as modifications in the shape of epithelial cells, conglutination and clumping of the microvilli, and the appearance of immunocompetent cells. Once patients were nCPAP mask compliant, mucociliary clearance was distinctly prolonged in all cases. CONCLUSIONS: A successful therapeutic concept should provide normalization of room temperature and air humidity once nCPAP mask compliance has been achieved, and include regular assessment of the condition of the mucosa in the upper respiratory tract. Only by these measures can nasal complications be countered or therapy be applied at an early stage.

Fine-structural investigations of the effect of nCPAP-mask application on the nasal mucosa.

The treatment success of nasal continuous positive airway pressure (nCPAP)-therapy is dependent, on the one hand, on the achieved relief of complaints and, on the other hand, on long-term patient compliance and avoidance of compliance-related complaints. Next to the problem of mask application, nasal complaints comprise the most frequently reported side-effects and are among the primary factors causing nCPAP-therapy to be discontinued prematurely. To assess the morphological changes in the nasal mucosa during nCPAP-therapy, we excised specimens of nasal mucosa tissue from 10 patients with obstructive sleep apnoea syndrome (OSAS) before and 3-10 months after establishing nCPAP-mask compliance. The specimens were examined by electron microscopy. In all these patients compliance with the CPAP-mask marked the initial part of therapy. In addition, mucociliary clearance was assessed by the saccharin test before and after therapy. In all patients the nasal epithelium underwent fundamental changes upon CPAP-therapy, which became manifest as modifications in the shape of epithelial cells, conglutination and clumping of the microvilli, and the appearance of immunocompetent cells. Once patients were nCPAP-mask compliant, mucociliary clearance was distinctly prolonged in all cases. A successful therapeutic concept should provide normalization of room temperature and air humidity once nCPAP-mask compliance has been achieved and include regular assessment of the condition of the mucosa in the upper respiratory tract. Only by these measures can nasal complications be countered or given therapy at an early stage.

[Myoepithelial carcinoma (malignant myoepithelioma) of the salivary glands. A case report]. / Das myoepitheliale Karzinom (malignes Myoepitheliom) der Speicheldrüsen. Eine Falldarstellung.

We report the rare development of a myoepithelial carcinoma in a pleomorphic adenoma involving the minor salivary glands in the buccal mucosa of a 78-year-old female. Tumor presented as a small asymptomatic left buccal mass. The initial dominant component of the neoplasm was a pleomorphic adenoma, while the minor component was a myoepithelial carcinoma. Recurrences of tumor after 2 and then 5 years were excised. Histopathological examination of the last tissue removed showed a pure myoepithelial carcinoma of the minor salivary glands without evidence for a pleomorphic adenoma. The clinical features, therapy, diagnosis, histopathology and literature are reviewed.

[Primary extramedullary plasmacytoma of the head-neck area]. / Das primär extramedulläre Plasmozytom in der Kopf-Hals-Region.

BACKGROUND: A primary extramedullary plasmacytoma of the head and neck is a rare neoplasm with an incidence of 1%. The clinical features depend on localization. PATIENTS: The clinical features, the method of diagnosis, and response to treatment of two cases with different localization were analysed. RESULTS: For diagnosis immunohistological and serological investigations are necessary. CONCLUSIONS: The method of treatment is determined by complete staging.

[Use of MR-controlled laser-induced thermotherapy in recurrent squamous epithelial carcinoma of the head-neck area]. / Einsatz der MR-gesteuerten laser-induzierten Thermotherapie (LITT) bei Plattenepithelkarzinomrezidiven im Kopf-Hals-Bereich.

BACKGROUND: The management of patients with recurrent carcinomas of the head and neck that had been treated before by surgery, radiation, and/or chemotherapy presents a considerable problem. The value of the MR-controlled laser-induced thermotherapy (LITT) was analysed as a new palliative treatment modality. METHOD: LITT was used in five patients with recurrent head and neck squamous cell carcinomas, who had undergone established methods of treatment. One patient with a primary laryngeal carcinoma, who refused surgery, was treated by LITT in addition to radiation. A Nd:YAG laser was used to deliver laser light via an applicator directly into the tissue and to produce tumor necrosis. Using two special MR thermosequences (Thermo-TurboFLASH-, modified FLASH-2 D-Sequenfe) the laser process was controlled on line. The necroses were measured by a static and dynamic area calculation program based on a pixel evaluation. RESULTS: The induced tumor necroses ranged from 4 cm3 to 28 cm3. In all cases the MR thermosequences showed a loss of the signal up to 15 mm around the top of the applicator. In the post-interventional T1 sequences with intensified contrast, the coagulation necroses were represented as hypovascular areas. No side effects were seen and five of the patients felt an improvement of clinical symptoms. CONCLUSION: LITT as a minimal invasive, MR-controlled method may be a good alternative in palliative therapy of head and neck carcinomas.

[Intra-arterial cisplatin and sequential radiotherapy. Long-term follow-up]. / Cisplatin intraarteriell und sequentielle Strahlentherapie. Langzeit-Ergebnisse.

BACKGROUND: The objective of this study was to improve the results of irradiation by prior application of intraarterial (i.a.) chemotherapy with cisplatin. METHODS: Sixty-three patients suffering from advanced head and neck cancer without previous treatment were prepared for intraarterial chemotherapy by neck dissection without resection of the primary tumor and by modification of the carotid artery by creating a more inferiorly positioned bifurcation to facilitate intermittent i.a. infusion. The patients received approximately 400 mg cisplatin over a period of four to five weeks followed by irradiation with 60Co (64 Gy HD). RESULTS: The survival rate at five years in all patients with adequate i.a. chemotherapy was 19 of 49 (39%), except those with adenoid-cystic carcinoma, who had a five-year-survival rate of 100%. CONCLUSION: The results indicate that inductive i.a. chemotherapy with cisplatin has a positive influence on the outcome of irradiation even in inoperable head and neck cancer, which is defined by a longer period of remission with the possibility of curing the disease.

[MR-guided laser-induced thermotherapy in tumors of the head and neck region: initial clinical results]. / MR-gesteuerte laserinduzierte Thermotherapie bei Tumoren in der Kopf-Hals-Region: Erste klinische Ergebnisse.

PURPOSE: To analyse the value of MR-guided laser-induced thermotherapy (LITT) for palliative treatment of recurrent tumours of the head and neck region. MATERIAL AND METHODS: 8 patients with recurrent tumours of the head and neck region (squamous cell carcinomas n = 6, pleomorphic adenomas n = 2) underwent MR-controlled LITT. A 7 French laser applicator was inserted under local anaesthesia into the centre of the recurrent tumour. A Nd:YAG laser with a wavelength of 1064 nm was used. Therapy was monitored on-line using special MR thermosequences. RESULTS: Preinterventional contrast-enhanced MRI revealed a recurrent tumour of the head and neck region for all eight patients. All patients tolerated the procedures well under local anaesthesia, with no clinically relevant side effects. The MR thermosequences depicted up to 15 mm diameter areas of less signal near the laser tip. Postinterventional contrast-enhanced MRI revealed hypovascularized areas due to the resulting coagulative necrosis. Coagulative necrosis of 4 cc to 28 cc occurred in all patients, and a reduction of clinical symptoms was achieved in five. CONCLUSION: The results obtained indicate that minimal invasive LITT can be a therapeutic alternative for palliative treatment of head and neck tumours.

Recurrent nasopharyngeal tumors: preliminary clinical results with interventional MR imaging--controlled laser-induced thermotherapy.

PURPOSE: To evaluate magnetic resonance (MR) imaging-controlled laser-induced thermotherapy (LITT) in the treatment of recurrent head and neck tumors. MATERIALS AND METHODS: Six patients with recurrent nasopharyngeal tumors (squamous cell carcinoma [n = 4], pleomorphic adenoma [n = 2]) underwent LITT with local anesthesia. A 7-F introducing sheath was inserted into the center of the tumor followed by a specially designed laser emitter. Therapy was monitored on-line with MR thermometry, and the amount of necrosis was estimated with dynamic and static contrast material-enhanced sequences. RESULTS: All procedures were well tolerated with use of local anesthesia, with no clinically relevant side effects. MR thermometry depicted up to 15-mm-diameter areas of less signal intensity near the laser tip. Coagulative necrosis was achieved in all patients (volume range, 4-28 cm3), and clinical symptoms were reduced in four. CONCLUSION: MR imaging-controlled LITT may be a safe, minimally invasive alternative in the treatment of recurrent head and neck tumors.

[Does malignant lateral cervical cyst still exist?]. / Gibt es die malignisierte laterale Halszyste doch?

A case of a carcinoma-in-situ developing in a lateral cervical cyst (branchiogenic carcinoma) is described and compared with metastatic cervical lymph nodes (due to cancers from unknown primary sites). The authors are convinced that branchial carcinomas do exist, but are extremely rare. The available literature is reviewed.

[Localized amyloidosis of the ENT area]. / Die lokalisierte Amyloidose im HNO-Bereich.

Although amyloidosis is in general a systemic disorder, it may occur as an isolated lesion, especially in the head and neck. The actual classification of amyloidosis is dependent on the biochemical nature of its protein deposits. In the present report, the symptoms and diagnosis of localized amyloidosis are discussed with special regard to histological findings.

[The basement membrane in diseases of the vocal cords: electron microscopy and immunomorphologic findings]. / Die Basalmembran bei Erkrankungen der Stimmlippen: Elektronenmikroskopische und immunmorphologische Befunde.

The basement lamina of the epithelium of the true vocal cords of 34 inpatients suffering from chronic laryngitis, Reinke's oedema and squamous cell carcinoma have been investigated with the electron and immunofluorescence microscope. In chronic laryngitis, the lamina fibroreticularis is thickened (due to collagen type VII), corresponding to the clinical finding. In this layer mobile cells of the connective tissue can be found. In cases of Reinke's oedema it is the lamina densa which might be thickened. In this disease, also lamina densa-like material can protrude into the lamina fibroreticularis, and the number of anchoring filaments is increased. In squamous cell carcinoma we found the basement lamina irregularly arranged and folded. The lamina densa was always interrupted by numerous small gaps and in some areas the basement membrane could not be identified over a long distance. Lamina densa-like material was also found between the tumour cells within the epithelium. With the immunofluorescence microscope this material was proven as laminin, collagen type IV and heparan sulfate proteoglycan. Our investigation shows that malignant as well as benign lesions of the true vocal cords are characterised by distinct fine structural findings even concerning the basement lamina.

[Arteria lusoria--a rare cause of dysphagia]. / Die Arteria lusoria--seltene Ursache einer Dysphagie.

A rare case of a 29-year old woman with aberrant right subclavian artery (A. lusoria) causing dysphagia is presented. This abnormality is generally silent and often an incidental x-ray finding. By means of a median thoracotomy the anomalous vessel was divided at its point of origin and an anastomosis to the ascending aorta with a graft was performed.

Recurrent cervical lymphadenopathy: differential diagnosis with color-duplex sonography.

In this prospective study 45 patients with cervical lymphadenopathy treated by operation, radiation and/or chemotherapy were examined by color-duplex sonography. The aim was to investigate the lymph node perfusion and to find out whether differentiation between benign and malignant nodal disease after therapy was possible by resistance and pulsatility indices. In 200 of 245 lymph nodes (82%) color-duplex sonography was able to detect perfusion. Using a pulsatility index (PI) threshold of 1.6 and resistance index (RI) threshold of 0.8, differentiation between reactive nodal enlargement and metastases was possible with an accuracy of 96%. Differentiation between lymphomas and metastases by RI and PI was not possible. Qualitative assessment of perfusional patterns was useful in detecting malignancy because reactively enlarged nodes showed greater hilar perfusion whereas metastases showed an increased peripheral perfusion. Lymphomas had both increased central and peripheral perfusions.

[Intraepithelial mast cells in the vocal cords and nasal mucosa]. / Intraepitheliale Mastzellen in der Stimmlippenund Nasenschleimhaut.

Leukocytes and mast cells have been described in the human nasal mucosa and epithelium of the lower airways (Bonneville 1988, Goodman and Lefrancois 1989, Guy-Grand 1991, Denburg 1992). In mast cells, heterogeneity of mucosal and connective tissue mast cells has been observed. In the present electron microscopic study, the epithelium of the upper airways (larynx and nose) of patients, suffering from chronic laryngitis, was examined with special regard to intraepithelial mast cells. Numerous mast cells were found in the stratum spinosum of the true vocal cords showing extensive elongated surface folds that had little contact to epithelial cells. Desmosomes were absent. Mucosal mast cells are characterised by four types of membrane-bounded granules, whereas serosal mast cells only showed two different types of granules and resembled blood basophiles. Migration of connective tissue mast cells into the epithelium could not be observed. According to our findings, mucosal and serosal mast cells belong to different cell lines.

[Magnetic resonance tomography and computerized tomography in tumor staging of mouth and oropharyngeal cancer]. / Magnetresonanztomographie und Computertomographie im Tumorstaging des Mundhöhlen-/Oropharynxkarzinoms.

30 patients with malignant tumours of the cavum oris and oropharynx were examined by MRI and CT to compare their accuracy for T-staging. There was histological information in all cases. Histological studies showed an accuracy in T-staging of 81% for MRI and 77% for CT. Differentiation between stages T2/T3 and T3/T4 is possible in 80% by CT and 84% by MRI. Tumours of the cavum oris and oropharynx of T1-stage are possible only in 1 of 3 cases. The use of T2-weighted sequences allows the best frequence of tumour representation in 89%. CT shows an earlier bone involvement than MRI. In addition, the ability to produce coronal and sagittal images by MRI makes it superior to CT in judging tumour extension.

[Palpation and sonography in after-care of head-neck tumor patients: comparison of ultrasound tumor entity parameters]. / Palpation und Sonographie in der Nachsorge von Kopf-Hals-Tumorpatienten: Vergleich sonographischer Dignitätsparameter.

The ranking of postoperative palpation and sonography is examined in respect of imaging of neck lymph node enlargement and neck lymph node metastases or lymphomas, using a prospective study involving 127 patients whose head and neck tumours had already undergone treatment. These patients had been subjected to tumour aftercare for an average period of 26 months. Sonography is well suited for detecting the presence of enlarged neck lymph nodes, the accuracy being 97.5%. In this study palpation was clearly less safely defined, the accuracy being only 85%. The following results were obtained in respect of the specific imaging of metastases: sensitivity of palpation (75%) is below that of sonography (M/Q ratio) (93%). In respect of specificity palpation also yielded poorer results than sonography (M/Q ratio 94%) because of the relatively high proportion of false positive palpations (17%). The reason for this is non-differentiation between reactively enlarged lymph nodes and lymph nodes metastases. The advantage of sonography vs palpation by using the M/Q ratio is therefore the accuracy of the findings (94% sonography, 81% palpation) and hence the clear reduction in false positive and false negative findings. Furthermore, sonography can image the exact relationship to surrounding tissue and especially the vessels. The drawback of sonography is that lymph nodes < 9 mm maximal diameter cannot be assessed with the safety and accuracy mentioned above. Sonomorphological criteria such as the central marrow reflex and a widened lymphatic node cortex enhance diagnostic safety of the sonographic expansion parameters to yield an assessment of tumour status.

[Esthesioneuroblastoma: diagnostic conformation by immunohistology and electron microscopy]. / Asthesioneuroblastom: Diagnosesicherung durch Immunhistologie und Elektronenmikroskopie.

The aesthesioneuroblastoma (olfactory neuroma) is a rare neuroepithelial tumour of the nasal cavity, the clinical symptoms of which become manifest very late in most patients. In general, with the light microscope used routinely (fixation of the specimens with formaldehyde, staining with haematoxylin-eosine) a malignant round cell neoplasia can be recognised without further differentiation. To ensure the diagnosis of an aesthesioneuroblastoma, immunohistological techniques (vimentin, S-100 protein, neurofilaments, neuron-specific enolase) are undoubtedly necessary. In some cases of unclear findings the electron microscope might be used to prove an aesthesioneuroblastoma. The immunohistological and electron microscopic features of aesthesioneuroblastoma are demonstrated and problems of histological differential diagnosis are discussed.

[Spiral CT: differential diagnosis of cervical swelling. Initial clinical results]. / Spiral-CT: Differentialdiagnose zervikaler Schwellungen. Erste klinische Ergebnisse.

Spiral CT examinations were performed pretherapeutically in 27 patients in whom cervical lymph node enlargement had been suspected. The M/Q quotient known from sonography and MR can also be employed in CT by means of coronary and sagittal reconstruction. This improves CT differentiation between reactively changed and metastatically infiltrated lymph nodes in tumour patients. Hence, CT diagnosis can now make use of a highly sensitive and highly specific criterion for diagnosing lymph nodes. Another diagnostic improvement is that vascular infiltrations by lymph node metastases can now be visualised or excluded more readily. Spiral CT is also suitable in tumorous and non-tumorous processes for an accurate assessment of the extension of e.g. retropharyngeal abscesses or laryngoceles.

[Lymph node metastases of the neck in unknown primary tumor: is there a differential imaging diagnosis?]. / Halslymphknotenmetastasen bei unbekanntem Primärtumor: Gibt es eine bildgebende Differentialdiagnostik?

In 32 patients suffering from cervical lymph node metastases with an unknown primary tumour the pretherapeutic findings via sonography, CT and MR were compared and the post-therapy findings of tumour aftercare assessed. After an average follow-up period of 38 months the group of branchiogenic cervical cysts had no recurrence. In the group of 18 patients with more than one cervical lymph node metastasis without primary tumour, either the primary tumour or further lymph node metastases became manifest in 11 patients after an average follow-up period of 36 months. Imaging of the number of lymph node metastases and differentiation between malignant degenerated branchiogenic cysts and lymph node metastases without primary tumour is important for prognosis. A combination of findings from sonography, CT and MR enables performance of such differential diagnosis due to morphological aspects and aspects that are conditioned by the contrast medium.